SCHOOL  HEALTH 
ADMINISTRATION  , 


BY 


LOUIS  W.  RAPEER,  M.A. 
NEW  YORK  TRAINING  SCHOOL  FOR  TEACHERS 


Submitted  in  partial  fulfillment  of  the  requirements  for  the  degree  of 

doctor   of  philosophy,  in    the  faculty   of  philosophy, 

Columbia    University. 


PUBLISHED  BY 

Ccacfjers  College,  Columbia  vLlntUrrsitp 

NEW  YORK  CITY 

1913 


V 


COPYRIGHT  1913,  BY  Louis  W.  RAPEER 


THE    HOWARD-GRAY   CO.,   PRINTERS, 
NEW    YORK    CITY 


PREFACE 

THE  problem  of  this  dissertation  is  to  find  what  Ameri- 
can cities  are  doing  for  national  health  and  vitality  through 
the  agency  of  the  public  schools,  and  how  this  work  may 
be  made  more  efficient  and  socially  useful  in  solving  our 
individual  and  national  health  problems.  The  scope  of  the 
work  is  enormous  and  necessarily  in  the  nature  of  a  rough 
survey,  rather  than  an  intensive  study  of  a  narrow  portion 
of  the  field.  Only  one  of  the  newest  phases  of  educational 
hygiene,  medical  inspection  of  schools,  has  been  very  thor- 
oughly investigated,  and  the  multiplicity  of  limitations  in 
this  field  has  made  great  accuracy  impossible.  No  very 
conclusive  results  have  been  obtained,  and  the  volume  is 
offered  merely  as  a  beginning  on  a  new  problem,  and  for  its 
suggestive  value  in  practical  administrative  improvement. 

The  investigation  began  with  the  practice  of  such  work 
in  the  writer's  own  school  when  a  principal  in  Minneapolis, 
and  more  directly  with  a  study  of  data  collected  by  the 
Child  Hygiene  Department  of  the  Russell  Sage  Founda- 
tion on  the  health  provisions  of  1,038  graded  school  systems 
under  superintendents.  It  has  since  broadened  into  a  study 
of  national  health  and  vitality,  a  survey  of  educational 
hygiene  in  twenty-five  of  forty  cities  visited  for  the  pur- 
pose, and  an  intensive  study  of  health  problems  in  one 
school  system  by  invitation  of  the  Board  of  Education. 
The  tentative  standard  plan  for  the  administration  of  medi- 
cal inspection  as  an  organic  part  of  the  whole  of  educational 
hygiene  here  offered  for  criticism,  is  an  outgrowth  of  the 
last  mentioned  study.  The  hope  back  of  the  dissertation  is, 
of  course,  that  the  health  conditions  of  our  nation  may 
be  improved. 


4  PREFACE 

To  prosecute  such  an  investigation  requires  the  co-oper- 
ation of  a  great  number  of  individuals.  In  this  case,  super- 
intendents, school  physicians  and  nurses,  dentists,  directors 
of  physical  education,  members  of  state  and  local  boards 
of  education,  health  officers,  principals,  teachers,  school 
janitors,  and  business  managers,  in  great  numbers,  in  the 
twenty-five  cities  especially,  have  cheerfully  contributed  to 
make  the  study  possible.  For  their  never-failing  courtesy 
and  unstinted  helpfulness  I  here  publicly  give  grateful 
acknowledgment.  To  Professors  George  D.  Strayer,  Ed- 
ward L.  Thorndike,  and  Henry  Suzzallo  of  Teachers  Col- 
lege, Columbia  University,  and  to  Doctor  Leonard  P. 
Ayres  of  the  Child  Hygiene  division  of  the  Sage  Founda- 
tion, the  author  is  much  indebted  for  encouragement  and 
many  valuable  constructive  suggestions.  My  wife  has  con- 
tributed at  every  step  to  make  the  study  possible. 

220  W.   1 20th  Street, 
New  York  City, 
Sept.,   1913. 


CONTENTS 

OUTLINE   ABSTRACT  7 

PART  ONE 

THE   NATIONAL   AND  SCHOOL  HEALTH    PROBLEM  AND 
How  IT  is  BEING  MET 

CHAPTER 

I.     THE  NATIONAL  HEALTH  PROBLEM 17 

II.     THE  SCHOOL  HEALTH  PROBLEM, 28 

III.  How  THE  HEALTH  PROBLEM  is  BEING  MET 

IN  SCHOOLS  AND  NATION. 

PART  TWO 

How  THE  PROBLEM  OF  EDUCATIONAL  HYGIENE  is  BEING 
SOLVED  IN  TWENTY-FIVE  CITIES 

IV.  GENERAL  PHASES  OF  HEALTH  ADMINISTRA- 

TION         7 1 

V.     THE  NATURE  AND  THE  EFFICIENCY  OF  THE 

WORK  DONE   107 

VI.     THE  AILMENTS  OF   PUBLIC   SCHOOL  CHIL- 
DREN.  A.    PHYSICAL  DEFECTS 134 

VII.     B.    COMMON  NON-INFECTIOUS  AILMENTS..   182 

VIII.     C.  &  D.    COMMUNICABLE  AILMENTS,  PARA- 
SITIC AND  INFECTIOUS 203 

IX.     SPECIAL  PHASES  OF  MEDICAL  INSPECTION  IN 

THESE  CITIES  228 

X.     PHYSICAL  EDUCATION  AND  OTHER  PHASES 

OF  EDUCATIONAL  HYGIENE^ 262 

PART  THREE 

XL     THE  ADMINISTRATION  OF  MEDICAL  INSPEC- 
TION— A  TENTATIVE  STANDARD  PLAN.  . .   295 

5 


TABLES  AND  FORMS 

NUMBER.  PAGE. 

I.  &  II.     Causes  of  Death  in  the  Registration  Area.  .22-23 

III.  Preventability     of     Death     of     Elementary 

School   Children    29 

IV.  Preventability   of    Deaths   of   High    School 

Children    30 

V.     General  Administration  of  Medical  Inspec- 
tion     76-77 

VI.     The  Work  of  Doctors  and  Nurses 80-8 1 

VII.     Accomplishment  in  Medical  Inspection. .  116-1 17 
VIII.     Ailments  of  School  Children.    Physical  De- 
fects  138-139 

IX.     Common  Non-Infectious   Ailments.  .  184-185-186 
X.     Communicable  Ailments,   Parasitic  and  In- 
fectious.   Deaths  of  Children. ..  .205-206-207 

XI.     Ailments  in  Order  of  Frequency 226-227 

XII.     Efficiency  Data.     Estimated  Needs  of  Cities    253 

XIII.  Approximate  Rank  of  the  Cities 254 

XIV.  Physical   Education    263 

XV.     Divisions  of  Educational  Hygiene    296 

XVI.  Individual  Health   Record,  Number  One..     311 

XVII.  Individual  Health  Record,  Number  Two.  .     315 

XVIII.  Weekly  Report  of  Doctors  and  Nurses.  .345-346 

XIX.  Classification  and  Frequency  of  Ailments..     351 


SCHOOL  HEALTH  ADMINISTRATION 

OUTLINE  ABSTRACT 
I.  GENERAL  METHOD  OF  THINKING 

In  general,  the  thought  is  that  before  we  can  say  what 
the  public  schools  are  or  should  be  doing  for  individual 
and  public  health  we  must  determine  as  accurately  as 
possible  with  present-day  statistics  what  the  health  needs 
and  problems  of  individuals  and  the  nation  actually  are, 
and  how  serious  the  health  problem  is,  compared  with  other 
grave  problems  of  life.  The  public  school's  share  in  the 
responsibilities  for  public  health  amelioration  is  very  great, 
and  growing,  due  to  the  lack  or  inefficiency  of  other  insti- 
tutions for  such  a  purpose,  to  the  admirable  conditions  of 
control  in  a  state  institution  and  with  compulsory  attend- 
ance and  general  community  support,  and  to  the  fact  that 
such  a  large  share  of  health  mal-adjustment  is  due  to  health 
ignorance,  and  the  lack  of  adequate  health  habits  and  ideals 
which  it  is  so  largely  the  special  function  of  the  public 
school  to  replace  with  positive  health  qualities.  The  princi- 
pal problems  of  life,  whatever  they  may  be,  and  to  be 
discovered  only  by  a  study  of  life  through  surveys  or  any 
other  efficient  means,  furnish  the  problems  of  public  edu- 
cation. 

II.  PART  ONE.    THE  NATIONAL  AND  SCHOOL  HEALTH  PROB- 
LEM AND  HOW  IT  IS  BEING  MET  IN  SCHOOL  AND 
NATION.     (SUMMARIZED  AT  END  OF  CHAP- 
TERS   TWO    AND    THREE.) 

Health  and  physical  vitality  are  all-important  to  the 
attainment  of  the  goal  of  life  (happiness  through  social 
efficiency),  but  they  are  being  very  poorly  provided  for, 
since : 


8        SCHOOL  HEALTH  ADMINISTRATION 

A.  The  national  health  losses  are  enormous  and  largely 
preventable,  for: 

1.  Approximately  1,600,000  of  our  population  die  each 
year,  42  per  cent,  or  about  670,000,  of  reasonably 
preventable  diseases.    The  economic  loss  in  deaths 
is  approximately  a  billion  dollars. 

2.  Approximately    3,000,000    persons    are    constantly 
seriously  ill  in  the  United  States,  largely  of  prevent- 
able diseases ;  and  this  occasions  an  economic  loss  of 
about  another  billion  dollars. 

3.  A  very  large  number  of  persons  suffer  from  many 
minor  ailments  which  lower  their  efficiency  and  cause 
absence  from  work,  which  makes  an  economic  loss 
of  another  very  large  sum. 

4.  Other  nations,  such  as  Sweden  and  Germany,  are 
succeeding  by  adequate  national  and  school  provi- 
sions in  lowering  the  losses  much  below  our  own. 

5.  Competent    authorities    have    estimated  in  various 
ways   the   large   preventability   of   these   losses  by 
reasonable  application  of  present  knowledge. 

6.  Such  preventability  can  be  seen  from  the  effects  of 
such  civic  improvements  as  pure  water  and  pure 
milk  supplies. 

B.  The  school  health  losses  are  enormous  and  largely 
preventable,  for: 

1.  Approximately  100,000  children  of  elementary  and 
high  school  age  die  each  year  in  the  United  States, 
65,000   of  whom   have  been   during  the  year  en- 
rolled in   a  public   school.     Of  these   40,000   and 
perhaps  50,000  are  reasonably  preventable.    Their 
education  has  been  socially  wasted  expenditure  of 
energy  and  money. 

2.  The  illness  losses  of  both  teachers  and  pupils  of  the 
public  schools  are  enormous,   coming  in  the  form 
of  personal   and  public  financial  loss,   of  lowered 
vital  efficiency  and  happiness,  and  of  elimination, 
non-promotion  and  retardation  at  school.    Tentative 
guesses  at  the  amount  of  each  of  these  last  three 


SCHOOL  HEALTH  ADMINISTRATION        9 

due  to  illness  as  the  chief  or  only  factor  are :  elim- 
ination, about  12  per  cent;  non-promotion,  about 
ii  per  cent;  retardation,  about  10  per  cent. 

3.  The  physical  defects  losses  are  also  enormous  and 
largely  preventable.    They  function  largely  in  caus- 
ing about:   five  per  cent  of  elimination,  six  per  cent 
of  non-promotion,  and  seven  per  cent    of  retarda- 
tion. 

4.  Combined,  the  two  factors  of  ill-health  and  physical 
defects  function  largely  in  causing  about:    15  per 
cent  of  elimination,  16  per  cent  of  non-promotion, 
and  17  per  cent  of  retardation. 

5.  These  results  are  not  the  only  ill-health  results,  of 
course,    but    whenever    these    are    related    to    the 
twenty  million  school  children  in  the  United  States, 
the  problem  of  school  health  stands  out  as  one  of 
the  greatest  before  the  public. 

6.  The  studies  reviewed  for  their  school  health  data 
here  are :   Strayer's  Introductory  Survey  to  the  1910 
Report  of  the  U.  S.  Bureau  of  Education,  Fisher's 
National   Vitality,    U.    S.    Mortality   Statistics    for 
1910,   Dr.  Keyes'  "Progress  Through  the  Grades 
of  City  Schools,"    the    studies    of    Retardation  by 
Ayres,  Strayer  and  Thorndike,  Dr.  Bachman's  re- 
port   in    the    New  York   City  School   Inquiry  of 
"Promotion,  Non-Promotion  and  Part  Time,"  Supt. 
Demarest's  1911  Study,  the  Boston  Non-Promotion 
Study,  Supt.  Broome's  1911  Study,  Supt.  Mackey's 
1911   Study,   Supt.  Verplanck's   1911    Study,   Supt. 
Brubacher's    1911    Study,  the  Newark  Quarantine 
and  Absence  Reports;  the  Ayres,  Cornell,  and  Wal- 
lin  studies,  and  a  few  others. 

7.  This  phase  has  not  been   exhaustively  studied  be- 
cause the  crux  of  the  investigation  is  the  work  of 
the  twenty-five  cities.     Other  data  to  emphasize,  by 
facts,  the  health  problem  of  schools  could  easily  be 
furnished  and  are  given  in  the  later  study  of  the 
ailments  of  school  children. 


io       SCHOOL  HEALTH  ADMINISTRATION 

C.  The  national  provisions  for  public  health,  in  the  fed- 
eral, the  state,  and  local  governments  are  comparatively 
numerous,  heterogeneous,  and  entirely  inadequate  to  meet 
the  national  health  needs  and  problems. 

Likewise  the  school  provisions  for  public  health  are 
numerous,  growing,  heterogeneous  and  entirely  inadequate, 
both  as  to  quantity  and  to  efficiency,  to  solve  satisfactorily 
the  school  health  problem.  The  science  and  the  practice 
of  educational  hygiene  are  in  their  infancy. 

Many  of  the  agencies  and  a  large  number  of  other  facts 
relating  to  national,  school,  and  private  provisions  for  public 
health  are  concisely  stated  in  chapter  three. 

Among  the  most  important  agencies  to  work  for  are : 
The  national,  state,  and  local  departments  of  health  and 
their  increased  scope  and  greatly  improvable  (the  last  two) 
efficiency,  and,  secondly,  efficient  and  scientific  departments 
of  Educational  Hygiene  in  federal,  state,  and  local  school 
systems  with  the  following  working  divisions :  medical  in- 
spection, the  teaching  of  hygiene,  school  sanitation,  physical 
education,  and  the  hygiene  of  teaching.  The  promise  for 
the  greatest  usefulness  lies  in  such  departments  under  expert 
direction. 

III.    INVESTIGATION  OF  EDUCATIONAL  HYGIENE  IN 
TWENTY-FIVE  CITIES 

A.  The  method  was  to  visit  forty  cities  and  select  from 
these  twenty-five  that  had  both  school  doctors  and  nurses 
and  had  had  the  work  in  progress  for  nearly  a  year  or 
longer.  Most  of  the  visits  were  made  in  1911,  but  for  wide 
acquaintance  with  the  work  they  have  been  continued  when- 
ever time  could  be  found  from  the  fall  of  1910  to  the 
spring  of  1913.  One  city  was  intensively  studied  for  the 
Board  of  Education  of  that  city.  All  reports,  blank  forms, 
the  methods  of  work,  and  all  public  provisions  for  public 
health  in  charge  of  the  school  or  other  organizations  dealing 
with  school  children  were  studied  so  far  as  data  could  be 
found  and  time  permitted.  The  work  is  in  the  form  of 
a  survey  with  some  intensive  study  of  several  phases,  and 


SCHOOL  HEALTH  ADMINISTRATION       n 

the  motive  has  been  to  avoid  any  tendency  toward  muck- 
raking and  to  make  the  study  entirely  constructive.  The 
writer  was  prejudiced  against  board  of  health  control  of 
medical  inspection  at  the  start,  and  this  has  been  offset 
by  giving  these  bodies  especially  favorable  consideration 
throughout. 

B.  The  work  of  medical  inspection  is  in  its  infancy  and 
is  yet  very  heterogeneous  and  inefficient.  The  organization  is 
poor  and  the  amount  of  money  spent  not  commensurate 
with  the  needs,  as  compared  with  other  legitimate  needs. 

C.  Board  of  Health  control  of  this  work,  even  though 
it  has  some  marked  advantages,  is,  on  the  whole,  less  efficient 
and  less  promising  for  the  future  than  Board  of  Education 
control. 

D.  Medical  inspection  is  at  present  isolated  from  other 
phases  of  educational  hygiene.     Many  promising  features 
of  the  development  of  the  four  other  phases  of  educational 
hygiene  in  these  cities  are  given  in  chapter  ten. 

E.  The  chapters  on  the  ailments    of    school    children 
give  a  close  view  of  the  fifty-four  classes  of  ailments  accord- 
ing to  the  tentative  standard  classification  presented,   and 
attempt  to  state  the  probable  frequency  of  such  ailments  in 
an  elementary  school  population  that  has  not  had  long  and 
efficient  medical  supervision.    Our  estimates  are  much  lower 
than  those  usually  given. 

F.  The  reader  is  here  referred  to  the  summary  of  con- 
clusions regarding  medical  inspection  found  in  chapter  nine, 
in  the  tables,  and  especially  in  the  tentative  standard  plan 
for  the  administration  of  this  work. 

IV.    TENTATIVE  STANDARD  PLAN  FOR  THE  ADMINISTRATION 
OF  MEDICAL   INSPECTION 

A.  The  plan  here  offered,  and  later  to  be  re-printed  for 
separate  use,  is  intended  to  be  applicable  as  a  beginning 
for  most  cities,  for  rural  areas,  and  for  any  group  of 
small  cities.  It  has  been  critically  tested  in  part  by  a  com- 
mittee that  has  studied  the  systems  of  reporting  and  ad- 
ministration in  seventy-five  cities,  and  is  believed  to  be 


12       SCHOOL  HEALTH  ADMINISTRATION 

superior  to  any  system  now  in  operation;  and  may  be  put 
into  operation  at  practically  the  same  expenditure  of  money 
as  any  well-provided  city  on  present  lines. 

B.  Every  administrative  area,  a  city,  a  group  of  cities, 
or  a  rural  area  such  as  a  district,  township,  or  county, 
depending  upon  the  number  of  children,  should  have  a 
director,  or  supervisor,  of  (educational)  hygiene.  Over 
*  these,  each  state  should  have  a  supervisor  of  hygiene.  This 
officer  should  have  the  qualifications  both  of  a  physician 
and  of  a  specialist  in  educational  hygiene.  Such  men  are 
now  to  be  had,  and  indications  point  toward  the  introduc- 
tion of  training  courses  for  doctors  of  educational  hygiene 
in  medical  schools  and  teachers'  colleges.  The  salary  at 
present  must  be,  at  least,  between  two  and  four  thousand 
/dollars  a  year,  of  eleven  months.  The  supervisor's  function 
will  be  to  correlate  and  supervise  all  phases  of  hygiene 
(medical  inspection,  physical  education,  school  sanitation,  the 
teaching  of  hygiene,  and  the  hygiene  of  teaching),  in  eon- 
junction  with  the  general  superintendent,  and  in  many  cases 
to  do  part  of  the  work  of  medical  inspection.  In  many 
systems  the  number  of  part-time  school  physicians,  phy- 
sical training  teachers  and  truant  officers  who  can  be  elim- 
inated will  be  great  enough  to  make  necessary  little  or  no 
increase  of  expenditure  for  his  salary.  Many  other  savings 
v  through  such  a  system  will  be  evident. 

C.  At  present,  no  good  plan  for  the  complete  elimina- 
tion of  part-time  work  on  the  part  of  assistant  school  phy- 
,  sicians  has  been  devised,  although  this  is  to  be  desired. 
The  plan  here  is  to  have  physicians  do  practically  no  other 
work  than  that  of  the  (physical)  examination  of  pupils, 
and  to  have  the  supervisor  of  hygiene,  where  possible,  do 
the  work  of  one  physician.  To  begin  with,  have  one 
physician,  counting  the  supervisor,  for  each  three  thousand 
children,  elementary  and  high  school,  and  one  nurse  for 
each  two  thousand  children,  depending  upon  circumstances 
as  to  the  exact  numbers.  Have  the  physicians  give  two 
hours  a  day  in  one  school  building  each,  making  medical 
examinations  of  the  pupils  (also  teachers  and  janitors)  and 


SCHOOL  HEALTH  ADMINISTRATION       13 

such  individual  inspections  as  are  urgent,  and  completing 
the  examination  of  the  allotted  number  of  pupils,  with  the 
help  of  an  assisting  nurse,  before  the  end  of  the  school  year.  ^ 
The  nurses  are  to  do  most  of  the  inspecting,  aside  from 
the  routine  September  room-inspection  of  all  children,  and 
also  the  home  visiting. 

D.  The  details  of  the  work  are  given  in  the  plan.  The 
reporting  and  record  system  should  be  adapted  and  adopted, 
including  the  tentative  standard  classification  off-school  ail- 
ments. The  doctor  has  no  traveling  about  from  school 
to  school  on  school  time  to  do,  and  he  is  likewise  freed 
from  making  reports.  Clerical  work  is  almost  entirely 
placed  in  the  hands  of  the  nurse.  This  is  the  greatest  piece 
of  economy  in  the  entire  plan,  when  seen  in  comparison v 
with  present  systems,  many  of  them  requiring  far  more 
time  at  clerical  work  and  inter-school  traveling  than  in 
actual  school  medical  service. 

E.  The  nurse-alone  plan  is  probably  best  in  very  poor 
districts,  unable  to  provide  a  complete  system.  Later,  phy- 
sicians can  be  added.  This  is  the  direct  opposite  of  the 
usual  plan,  of  employing  physicians  and  then,  if  possible, 
adding  nurses.  The  nurse's  service  is  usually  cheap,  efficient,  <- 
and  directed  toward  getting  the  results  that  count:  preven- 
tion and  cures.  So  far  as  inspection  goes,  nurses  are  able 
to  find  most  of  the  serious  cases  needing  care  and  treat- 
ment. We  very  much  need  better  training  of  nurses  for 
school  work,  but  not  any  more  than  we  need  such  train- 
ing for  school  physicians.  We  prophesy  that  well-trained 
school  nurses  will  soon  take  the  place  of  part-time  physicians 
in  medical  supervision.  There  will  be  a  supervisor  of 
hygiene  with  assistants,  and  physicians  in  school  clinics. 

F.  The  plan  as  here  offered  for  trial  is  not  guaranteed 
perfect.  It  is  very  imperfect,  and  nothing  will  take  the 
place  of  careful  study  of  local  conditions,  careful  adaptation 
of  this  and  other  plans,  and  careful  training  of  doctors, 
nurses,  teachers,  and  pupils  in  carrying  it  out  efficiently. 
The  skilled  medical  supervisor  will  be  necessary  for  this 
work  with  any  plan,  and  scientific  supervision  and  study  will 
be  sure  to  bring  health  results. 


EXPERIMENTAL  EDUCATION  FOR 
SCHOOL  PROBLEMS 

"My  first  and  in  some  respects  my  deepest  im- 
pression of  the  evening  spent  so  enjoyably  in 
Edison's  laboratory  is  not  directly  connected  with 
the  educational  value  of  his  motion  picture 
scheme.  It  is  rather  of  the  immense  advantage 
a  great  commercial  enterprise  has  over  the  great- 
est of  our  existing  educational  institutions  in  the 
matter  of  conducting  systematically  an  experi- 
mental development  of  a  new  proposal  before 
putting  it  into  general  practice. 

"No  intimation  was  given  of  the  sum  of  money 
that  is  being  put  into  the  development  of  this 
new  undertaking.  But  it  is  clear  that  a  large 
staff  is  employed  to  develop  'scenarios'  to  make 
suggestions  and  criticisms,  and  to  try  out  various 
schemes,  in  addition  to  the  expense  involved  in 
taking  the  pitcures  themselves.  A  large  sum  of 
money  will  have  been  spent  before  pecuniary 
returns  begin  to  come  in — a  good  deal  of  it  strict- 
ly experimental  inquiry. 

"Where  is  there  a  school  system  having  at 
command  a  sum  of  money  with  which  to  investi- 
gate and  perfect  a  scheme  experimentally,  be- 
fore putting  it  into  general  operation?  And  can 
we  expect  continuous  and  intelligent  progress  in 
school  matters  until  the  community  adopts  a 
method  of  procedure  which  is  now  a  common- 
place with  every  great  industrial  undertaking? 
Is  not  the  existing  method  of  introducing  re- 
forms into  education  a  relic  of  an  empirical  cut- 
and-try  method  which  has  been  abandoned  in 
all  other  great  organizations?  And  is  not  the 
failure  to  provide  funds  so  that  experts  may 
work  out  projects  in  advance  a  pennywise  and 
pound-foolish  performance?" — John  Dewey,  in 
the  Survey  for  September  6,  1913. 


PART  ONE 

THE   NATIONAL   AND   SCHOOL    HEALTH   PROBLEM 
AND  HOW  IT  IS  BEING  MET 


THE    NATIONAL   HEALTH    PROBLEM 

"In  the  continental  United  States  with  over  90 
million  souls  probably  2*/2  million  children  are 
annually  born.  When  we  think  of  the  influence 
of  a  single  man  in  this  country,  of  a  Harriman, 
of  an  Edison,  of  a  William  James,  the  poten- 
tiality of  these  2.^/2  million  annually  can  be  dimly 
conceived  as  beyond  computation.  But  for  bet- 
ter or  worse  this  potentiality  is  far  from  being 
realised.  Nearly  half  a  million  (one- fifth)  of 
these  infants  die  before  they  attain  the  age  of 
one  year;  and  half  of  all  are  dead  before  they 
reach  their  twenty-third  year — before  they  have 
had  much  chance  to  affect  the  world  one  way 
or  another.  However,  with  only  one  and  a 
quarter  million  of  the  children  born  each  year — 
destined  to  play  an  important  part  for  the  nation 
and  humanity  we  could  look  with  equanimity  on 
the  result.  But  alas!  only  a  small  part  of  this 
army  will  be  fully  effective.  On  the  contrary, 
of  the  1200  thousand  who  reach  full  maturity 
each  year  40  thousand  will  be  ineffective  through 
temporary  sickness,  4  to  5  thousand  will  be 
segregated  in  the  care  of  institutions,  unknown 
thousands  will  be  kept  in  poverty  through  mental 
deficiency,  other  thousands  will  be  the  cause  of 
social  disorder  and  still  other  thousands  will  be 
required  to  tend  and  control  the  weak  and  un- 
ruly. We  may  estimate  at  not  far  from  100 
thousand,  or  8  per  cent.,  the  number  of  non- 
productive or  only  slightly  productive,  and  prob- 
ably this  proportion  would  hold  for  the  600 
thousand  males  considered  by  themselves." — 
Davenport,  in  "Heredity  in  Relation  to  Eu- 
genics!' 


CHAPTER  ONE 
THE  NATIONAL  HEALTH  PROBLEM 

I.  EDUCATION  AND  PUBLIC  HEALTH 

HEALTH  is  the  fundamental  prerequisite  for  both  indi- 
vidual and  social  happiness  and  efficiency.  It  stands  in  such 
intimate  and  vital  relationship  to  existence  itself  and  to  the 
first  law  of  life,  self-preservation,  that  it  must  ever  be  a 
foremost  problem  of  individual  and  social  policy.  The 
primary  business  of  a  sick  man  is  to  get  well  and  to  stay 
well;  likewise,  the  primary  business  of  the  public  and  the 
state  is  to  provide  for  healthful  conditions  and  healthy  lives. 
Private  and  social  practice  which  preserves  and  promotes 
health  and  abundant  life  is,  from  this  standpoint,  good; 
that  which  contributes  to  ill-health  or  race-degeneracy, 
though  it  bring  forth  some  of  the  best  of  the  goods  of  life, 
is  wrong.  Theoretically,  at  least,  everyone  will  agree  with 
the  thought  emblazoned  in  great  letters  over  the  stage  in 
Der  Mensch  building  at  the  recent  International  Hygiene 
Exhibition  at  Dresden:  No  Wealth  Is  Equal  to  Thee, 
O  Health.1 

That  a  very  much  larger  proportion  of  people  than  nec- 
essary are  not  realizing  this  great  eternal  value  of  life, 
good  health,  is  also  a  matter  of  common  knowledge.  The 
progress  of  medical  and  sanitary  science  in  the  last  fifty 
years  has  brought,  one  by  one,  most  of  the  insidious  destroy- 
ers of  life  and  health  into  the  light  of  day.  These  discov- 
eries have  not  only  overturned  hoary  health  traditions,  such 
as  the  commonly  accepted  opinion  that  malaria  and  yellow 
fever  were  caused  by  "night  air"  instead  of  by  the  bills 
of  certain  ubiquitous  mosquitoes,  but  they  have  followed 


1 8       SCHOOL  HEALTH  ADMINISTRATION 

each  other  in  such  rapid  succession  that  health  science, 
known  by  the  few,  is  today,  at  least  twenty,  and  in  many 
ways  forty,  years  ahead  of  common  knowledge  and  general 
practice.2  It  is  the  purpose  of  this  chapter  to  face  the  health 
problem  of  the  nation  and,  so,  of  the  schools,  endeavoring 
to  determine  something  of  its  nature  and  extent  and  the 
responsibility  it  places  upon  public  school  systems. 

Probably  the  most  important  scientific  studies  of  public 
health  in  America  recently  are  Professor  Fisher's  "National 
Vitality"3  and  Flexner's  "Medical  Education  in  the  United 
States  and  Canada"4 ;  the  first,  by  the  statistical  methods 
evolved  by  the  great  life  insurance  companies,  outlining 
the  enormous  extent  and  the  tremendous  importance  of  the 
problem ;  and  the  second,  by  personal  visitation  and  scientific 
methods,  determining  the  almost  criminal  inadequacy  of 
many  of  the  present  instruments  for  providing  health  lead- 
ers.5 In  the  first  is  given  at  length  the  evidences  and  facts 
relating  to  the  improvability  of  health  conditions  in  this 
country.  Fisher  shows  the  methods  by  which  eighteen  ex- 
perts in  various  diseases,  mortality  statistics,  and  sanitary 
science  determined  the  ratio  of  preventability  for  the  ninety 
different  causes  of  death  into  which  mortality  is  classified. 
This  ratio  is  defined  as  "the  fraction  of  all  deaths  which 
would  be  avoided  if  knowledge  now  existing  among  well- 
informed  men  in  the  medical  profession  were  actually  ap- 
plied in  a  reasonable  way  and  to  a  reasonable  extent."*'  That 
the  ratios  thus  determined  are  careful,  conservative  figures, 
not  implying,  for  example,  any  advance  in  medical  discov- 
eries nor  the  complete  socialization  of  health  knowledge 
now  possessed  by  the  few,  an  inspection  of  his  table  of 
ratios  will  quickly  show.  Most  persons,  perhaps,  would  in- 
crease many  of  these  ratios,  since  the  race  is  slowly  coming 
to  take  the  view  expressed  by  Pasteur  when  he  said  that 
"*'/  is  within  the  power  of  man  to  rid  himself  of  every  para- 
sitic disease"  We  have  reason  to  believe  in  "the  improv- 
ability of  man,"  and  we  know  that  the  first  step  and  con- 
dition of  such  conscious  evolution  is  health  and  life  itself. 


NATIONAL  HEALTH  PROBLEM  19 

II.    NATIONAL    HEALTH    LOSSES 

A.  In  Preventable  Deaths 

The  recently  published  federal  "Mortality  Statistics"7 
for  the  year  1910  show  that  in  the  "registration  area" 
of  continental  United  States  over  eight  hundred  thousand 
persons  died  (805,412).  The  registration  area  consists  of 
those  states  and  cities  that  are  conscious  enough  of  their 
health  problems  to  enforce  such  recording  of  deaths  as  will 
be  accepted  by  the  Census  Bureau.8  This  area  consists  of 
twenty-two  states,  counting  the  District  of  Columbia 
(City  of  Washington)  as  a  state,  and  forty-three  cities  in 
non-registration  states,  and  including  about  three-fifths  of 
the  population  of  continental  United  States  (53,843,896  out 
of  92,309,348  or  58.3  per  cent).9  The  registration  area  for 
births  is  very  much  smaller. 

It  is  impossible,  then,  for  the  people  of  the  United 
States,  as  contrasted  with  several  modern  nations,  to  know 
accurately  either  the  national  birth  rate  or  death  rate.  Com- 
paratively lax  enforcement  of  registration  laws  in  many 
places  makes  even  the  statistics  from  the  registration  area 
underestimates.  The  statistical  death  rate  of  this  area  for 
the  year  1910  is,  however,  15  per  1000  population,  the 
annual  average  for  ten  years  being  about  sixteen;  and,  for 
the  year  1910,  16.1  in  registration  cities,  14.7  in  registra- 
tion states,  15.9  in  cities  of  registration  states,  13.4  in  the 
rural  portion  of  registration  states,  and  16.9  in  the  regis- 
tration cities  of  other  states.10  Wilcox  estimates  the  true 
average  death  rate  for  the  United  States  as  18  a  thousand.11 

Using  the  ratio  of  registration-area  population  to  the 
total  population,  58.3  per  cent,  and  the  number  of  deaths 
occurring  in  the  registration  area,  805,412,  we  can  com- 
pute the  probable  death  loss  for  the  country.  Or,  we  can 
find  what  an  average  death-rate  of  fifteen  a  thousand  would 
mean  for  the  entire  population,  92,843,896  (July  i,  1910, 
estimate).  From  such  computation  we  get  a  total  death 
loss  to  continental  United  States  of  1,392,660.  Applying 
the  estimate  of  Wilcox,  18,  we  obtain  a  loss  of  1,671,228, 
Professor  Fisher  considers  18  as  a  minimum  true  rate,  and 


20       SCHOOL  HEALTH  ADMINISTRATION 

this  seems  reasonable,  so  a  death  loss  for  1910  of  1,600,000 
seems  entirely  conservative,  and  would  probably  be,  too, 
very  near  the  average  number  of  deaths  year  by  year.  In 
other  words,  a  little  less  than  two  per  cent  of  our  total  pop- 
ulation dies  each  year,  and  at  the  exceedingly  low  median 
aSe  °f  3$.12  How  much  of  this  astounding  death  loss  is 
unnecessary  and  preventable  we  shall  now  try  to  see. 

PREVENTABLE  VITAL  AND  ECONOMIC  LOSSES 

The  average  ratio  of  preventability  for  these  death 
losses,  as  computed  by  Fisher  from  the  combined  conser- 
vative estimates  furnished  by  the  eighteen  experts,  ranging 
in  eighteen  cases  from  zero  for  such  diseases  as  epilepsy 
to  85  per  cent  preventable  for  typhoid  fever,  alcoholism, 
and  puerperal  septicemia,  is  found  to  be  42.3  per  cent.13  In 
other  words  two-fifths  of  the  deaths  now  occurring  in  the 
United  States  are  reasonably  preventable  or  postponable. 
With  the  advance  of  medical  science  each  year  this  ratio 
will  rise.  Even  as  the  above  lines  were  being  written, 
March  22,  1912,  word  came  from  the  United  States  Hy- 
gienic Laboratory  that  Director  Anderson  and  Surgeon 
Goldberger  had  scientifically  demonstrated  that  the  "prin- 
cipal, if  not  the  only,  means  of  spreading  typhus  fever"  was 
pediculae  (head  lice),  the  trouble  found  more  frequently 
and  more  commonly  in  most  cities  by  medical  inspectors  of 
schools  than  any  other  ailment,  with  the  exception  of  den- 
tal caries.14 

Applying  this  figure,  42  per  cent,  to  the  estimated  num- 
ber of  deaths  each  year  we  get  as  the  number  of  pre- 
ventable deaths  occurring  annually,  672,000. 

What  does  the  preventable  and  unnecessary  loss  of  life 
of  over  670,000  persons  in  a  normal  year  mean  in  anguish, 
illness,  and  money  to  the  people  of  the  United  States? 
The  psychological  losses  of  this  character,  although  the 
most  terrible  of  earth's  sorrows,  we  are  as  yet  unable  to 
estimate.  The  average  family  is  about  four,  so,  at  least, 
three  times  as  many  persons  (2,010,000)  annually  are  ex- 
tremely intimately  and  seriously  affected. 


NATIONAL  HEALTH  PROBLEM  21 

ECONOMIC    DEATH    LOSSES 

Various  methods  of  computing  the  economic  losses  have 
been  worked  out.  Doctors  Locke  and  Floyd  of  the  Out- 
Patient  Department  of  the  Boston  Consumptives  Hospital 
have  recently  patiently  investigated  the  economic  loss  re- 
sulting from  500  male  consumptives,  who  had  visited  the 
hospital  in  the  last  five  years.15  The  capitalized  value  of 
the  earnings  cut  off  by  the  deaths  of  244  of  the  men  is 
computed  as  about  a  million  and  a  half  dollars,  or  an 
average  of  about  $6,164  each. 

Professor  Fisher's  calculated  "average  economic  value 
of  the  lives  now  sacrificed  by  preventable  deaths,  using  the 
age  distribution  of  deaths,  and  the  percentages  of  preven- 
tability"  is  $1700  each.16 

For  the  670,000  preventable  deaths  in  this  country  in 
1910,  we  should  have  a  financial  loss  to  the  nation  equal  to 
the  product  of  these  two  figures  (670,000  times  $1700) 
which  is  $1,139,000,000,  considerably  over  a  billion  dollars. 

The  accompanying  table  and  summary  have  been  made 
by  condensing  the  U.  S.  Mortality  Statistics  which  give  189 
causes  of  death.  Table  II,  given  in  italics,  is  here  included. 
B.  National  Illness  Losses.  Vital  and  Economic 

But  many  are  ill  for  each  one  who  dies.  uFew  who  have 
not  studied  the  facts  realize  how  common  illness  is,  although 
we  all  know  it  is  sufficiently  common  to  make  the  question 
'How  are  you?'  the  ordinary  form  of  salutation."  The 
above  mentioned  Report  of  the  National  Conservation  Com- 
mission on  National  Vitality  (page  741)  furnishes  the 
estimate  that  in  the  United  States  there  are  constantly  three 
million  persons  on  the  sick  list.  It  is  computed  that  750,000 
of  these  cases  (in  1907)  are  those  of  persons  thrown  out 
of  employment  by  their  illness.  The  average  earnings, 
computed  as  $700  a  year,  lost  each  year  in  this  way  would 
then  be  750,000  times  $700,  which  is  over  $500,000,000, 
a  half  billion  dollars. 

If  we  take  more  recent  statistics  of  annual  wages  and 
the  present  amount  of  illness,  we  obtain  other  figures.  Pro- 
fessor Scott  Nearing  computes  from  a  wide  study  of  our 
wage  statistics  in  industrial  sections  "that  half  of  the  adult 


22      SCHOOL  HEALTH  ADMINISTRATION 


CAUSES    OP    DEATH    FOR    THE 

REGISTRATION    AREA 

1910.* 

Age 
group 

All 

Children  of  School  Ages. 

Total,  of  most 

Ages. 

5  to  9 

10  to  14 

15  to  19 

5-14 

deaths 

All 

Causes    ..805,412 

17,943 

11,736 

19,772 

29,679 

0-   1 

I.   General    diseases     ....           ..215692 

8,891 

4,978 

9,770 

13,869 

25-29 

1. 

Typhoid  fever    

12,673 

684 

854 

1,681 

1,537 

20-24 

2. 

Malaria     

1,167 

58 

40 

67 

98 

20-24 

3. 

Small    pox    

202 

6 

6 

17 

12 

0-   1 

4. 

Measles     

6,598 

588 

152 

112 

740 

1-   2 

5. 

Scarlet  fever   

6,255 

1,731 

442 

232 

2,173 

5-   9 

6. 

Whooping  cough    

6,146 

228 

17 

10 

245 

0-   1 

7. 

Diphtheria   and    croup  

11,521 

2,938 

700 

228 

3,638 

5-   9 

8. 

Influenza      

7,774 

122 

73 

119 

195 

70-74 

9. 

Cholera    nostras     

536 

14 

8 

7 

22 

0-   1 

10. 

Dysentery     

3,446 

47 

15 

13 

62 

0-   1 

11. 

Erysipelas     

2,442 

8 

14 

35 

22 

0-   1 

12. 

Other   epidemic   diseases  .... 

198 

23 

11 

3 

34 

0-   1 

13. 

Purulent    infection,    etc  

1,877 

73 

62 

86 

135 

0-  1 

14. 

Rabies     

64 

13 

9 

6 

22 

5-  9 

15. 

Tetanus     

1,373 

162 

153 

88 

315 

0-   1 

16. 

Pellagra      

368 

4 

5 

12 

9 

30-34 

17. 

Tuberculosis    (of   lungs)  .... 

73,214 

489 

1,048 

5,166 

1,537 

25-29 

18. 

Tuberculosis    (other)     

13,095 

933 

586 

933 

1,519 

20-34 

19. 

Rickets     

455 

13 

8 

4 

21 

0-   1 

20. 

Syphilis     

3,221 

24 

11 

36 

35 

0-   1 

21. 

Gonococcus   infection    

197 

1 

17 

1 

0-   1 

22. 

Cancer  and  other  m.   tumors 

41,039 

83 

76 

152 

3 

60-64 

23. 

Other   tumors     

553 

9 

4 

6 

13 

65-74 

24. 

Acute  articular  rheumatism. 

3,328 

327 

357 

261 

684 

10-14 

25. 

Diabetes      

8,040 

144 

206 

258 

350 

60-64 

26. 

Leuchemia      

864 

44 

35 

39 

79 

40-55 

27. 

Anemia,    chlorosis    

2,614 

39 

40 

70 

79 

60-64 

28. 

Other   general    diseases  

5,014 

4 

10 

67 

14 

0-   1 

II. 

Nervous    Sys.  —  Special    Sense 

77,991 

1,368 

889 

976 

2,257 

70-74 

29. 

Encephalitis     

761 

34 

37 

39 

71 

0-   1 

30. 

Meningitis    

7,619 

683 

365 

294 

1,048 

0-   1 

31. 

Spinal  cord,  other  dis  

4,101 

264 

146 

130 

410 

65-69 

32. 

Aploplexy,    cereb.    hem  

39,701 

47 

46 

103 

93 

70-74 

33. 

Paralysis,  without  spec,  cause 

7,756 

27 

21 

29 

48 

70-74 

34. 

Epilepsy     

2,287 

79 

118 

172 

197 

25-29 

35. 

Convulsions   (nonpeuperal)    . 

200 

54 

9 

18 

63 

5-  9 

36. 

Chorea,    St.   Vitus   Dance  .  .  . 

123 

13 

18 

41 

31 

15-19 

37. 

Nervous   system,   other   D  .  .  . 

2,069 

70 

58 

63 

128 

50-54 

38. 

Ear   diseases    

967 

92 

64 

46 

156  Underl 

III. 

Circulatory  System    

100,106 

999 

1,319 

1,447 

2,318 

65-69 

39. 

Pericarditis     

650 

32 

32 

14 

64 

65-69 

40. 

4,792 

203 

226 

196 

429 

55-59 

41. 

Organic  D.  of  the  heart  

76,178 

716 

1,011 

1,158 

1,727 

70-74 

42. 

Angina    pectoris    

3,869 

7 

12 

17 

19 

65-69 

43. 

Embolism    and    thrombosis.  . 

1,990 

20 

19 

33 

39 

65-69 

44. 

Lymphatic   system,   Dis  

255 

14 

9 

9 

23 

0-   1 

IV. 

Respiratory   System    

100,835 

2,035 

956 

1,517 

299 

0-   1 

45. 

Nasal  fossae  Disease   

135 

9 

9 

5 

14 

0-   1 

46. 

Larynx,   Dis.   of    

746 

90 

13 

11 

103 

0-   1 

47. 

Bronchitis,    acute    

7,229 

90 

21 

21 

111 

75-79 

48. 

Bronchitis,    chronic     

5,391 

62 

30 

36 

92 

75-79 

49. 

Bronchopneumonia     , 

25,337 

522 

148 

158 

670 

0-   1 

50. 

Pneumonia     

54,187 

1,138 

664 

1,140 

1,802 

0-   1 

51. 

Pleurisy      

2,150 

66 

32 

83 

98 

60-64 

52. 

Pulmonary    cong't'n,    P.    Ap 

24,499 

28 

17 

17 

45 

0-   1 

53. 

Other  D.   of   Resp.    System  .  . 

1,174 

16 

13 

28 

29 

0-   1 

V. 

Digestive  System    

104,801 

1,669 

1,270 

1,429 

2,939 

0-   1 

54. 

Mouth   and  annexa,   D  

423 

11 

4 

6 

15 

0-   1 

55. 

Pharynx      

840 

123 

51 

40 

174 

5-  9 

56. 

Ulcer  of   stomach    

2,203 

13 

18 

47 

31 

45-49 

57. 

Other  D.  of  stomach   (not  c) 

8,403 

116 

57 

73 

173 

0-   1 

58. 
59. 
56. 

Diarrhea    and    enteritis  
Appendicitis    and    typhlitis.  . 

63,180 
6,128 
2,192 

469 
571 
8 

132 
718 
6 

91 
754 
21 

601 
1,289 
14 

0-   1 
15-18 
65-69 

57! 

Intestinal     obstruction  

4,486 

127 

88 

117 

215 

0-   1 

58, 

Other  diseases  of  the  Intest. 

1,571 

25 

20 

22 

45 

0-   1 

'Condensed   from  the  table  giving   189  different  causes. 


NATIONAL  HEALTH  PROBLEM 


TABLE  I. — Continued. 


59.  Cirrhosis  of  liver  

7,485 

15 

16 

25 

31 

50-54 

60.  Other  diseases  of   liver  

3,092 

36 

35 

34 

71 

60-64 

61.   Peritonitis    (nonpuep)  

2,419 

132 

109 

162 

241 

20-24 

62.  Other  D.  of  digestive  system 

329 

9 

4 

7 

13 

50-54 

VI.   Genito  -urinary    Sys.    Nonv 

62,559 

509 

447 

780 

956 

70-74 

63.  Nephritis    acute     

5,665 

253 

165 

199 

418 

40-44 

64.  Bright's     disease     

47,665 

224 

263 

440 

487 

70-74 

65.  Kidneys,   other   D.   of    

1,389 

22 

6 

16 

28 

0-   1 

66.   Other  D.  of  uterus  

774 

1 

5 

29 

6 

25-29 

67.  Salpingitis,  and  other  F.  D. 

1,298 

1 

2 

75 

3 

25-29 

VII.  The   pueperal    state  

8,455 

11 

620 

11 

25-29 

VIII.  Skin  and   cellular1  tissue. 

3,008 

26 

14 

31 

40 

0-   1 

68.  Gangrene      

1,748 

10 

7 

8 

17 

75-79 

69.  Abscess,    acute     

506 

12 

5 

9 

17 

0-   1 

IX.  Bones  and  locomotion  organs 

1,317 

100 

95 

89 

195 

0-  v 

70.  Bones,   not  T.   B  

1,145 

93 

90 

81 

183 

0-   1 

71.  Joints,  not  T.  B.  or  Rheum. 

119 

6 

4 

5 

10 

35-39 

X.  Malformations     

7,998 

76 

36 

20 

112 

0-  1 

72.  Hydrocephalus      

685 

30 

11 

4 

41 

0-  1 

73.  Congen.   M.   of  heart  

4,821 

33 

25 

13 

55 

0-   1 

XI.  Early    Infancy    

0-  1 

XII.  Old  age    

80-84 

XIII.  External   Causes    

57,196 

2,193 

1,678 

3,024 

3,871 

25-30 

74.   Suicide      

8,590 

1 

31 

326 

32 

35-39 

75.  Accidental    or    undefined.... 

45,416 

2,161 

1,599 

2,525 

3,760 

20-24 

XIV.  Ill  Defined  Diseases 12,462 


74 


43 


117      75-79 


males  of  the  United  States  (at  least  east  of  the  Rockies 
and  north  of  the  Mason  and  Dixon  line)  are  earning  less 
than  $500  a  year;  that  three-quarters  of  them  are  earning 
less  than  $600  annually;  that  nine-tenths  are  receiving  less 
than  $800  a  year,  while  less  than  ten  per  cent  receive 
more  than  that  figure."17  $550  or  $600  would  then  be, 
perhaps,  a  more  characteristic  figure  than  the  $700  taken  by 
Fisher.  However,  considering  the  increase  in  average  num- 
ber of  illnesses  since  1907  and  the  conservative  character 
of  the  findings,  we  may  let  the  annual  potential-earnings- 
loss  through  illness  stand  as  five  hundred  million  dollars. 

The  Nearing  wage  statistics,  in  the  light  of  the  com- 
puted minimum  standards  of  living,  will  be  found  useful 
later  on  in  throwing  light  on  the  cause  of  malnutrition 
and  other  ailments  of  school  children  and  the  necessity  of 
free  treatments  of  children  in  school  clinics. 

The  Locke  and  Floyd  investigations,  above  referred  to, 
show  that,  of  the  500  male  consumptive  cases  (41  per 
cent  between  the  ages  of  twenty  and  thirty-nine),  by  May  i, 


24       SCHOOL  HEALTH  ADMINISTRATION 

1911,  the  date  of  the  investigation,  the  244  dead  men  had 
lost  an  average  of  58.03  weeks  of  work  from  the  onset  of 
their  disease  until  death.  Their  average  weekly  wages  had 
been  $11.89  and  their  total  loss  was,  therefore,  $170,965. 
The  256  living  cases  had  lost  an  average  of  89.3  weeks 
of  work  at  an  average  wage  of  $11.38,  a  combined  loss 
of  $255,074,  making  a  total  loss  in  wages  alone  to  the 
five  hundred  men  of  $426,039,  an  average  of  $852  each. 

ECONOMIC  LOSSES  IN  MEDICAL  CARE 

But  lost  wages  are  not  the  only  illness  losses.  There 
is  the  further  expenditure  for  medical  attendance,  medicine, 
nursing,  etc.  These  five  hundred  sick  men  selected  at  ran- 
dom, cost  the  city  of  Boston  in  public  hospital  and  other 
institutional  care  $73,984.  This  is  exclusive  of  large  sums 
spent  by  private  organizations  on  406  out  of  the  500  cases. 
This  makes  the  loss  of  wages  and  cost  of  medical  care  at 
least  $500,023  plainly  accounted  for.  With  the  first  item 
of  loss-of-potential-earnings  through  preventable  death  of  the 
244  men,  we  have  a  total  economic  loss  of  about  $2,000,000; 
and  256  cases  were  not  yet  ended  by  death  or  cured. 

The  first  group  lost  in  wages  $618.28  in  a  year  of  52 
weeks;  the  second  group  lost  $591.76  in  the  same  time.  So 
we  could  say  that  the  annual  loss  in  wages  for  these  men 
was  on  the  average  $600.  The  total  number  of  weeks  lost 
by  both  groups  was  37,020,  an  average  of  74  each.  In  a 
year  of  52  weeks  of  this  time,  their  cost  to  the  municipality 
of  Boston  was  about  52/74  of  $73,984,  or  $51,988. 
This  is  an  average  cost  for  each  man  of  over  a  hundred 
dollars  a  year  ($103.97,  practically  $104). 

The  cost  in  care  to  the  relatives  of  these  men  and  the 
cost  to  private  philanthropic  institutions  is  not  given. 

"The  cost  per  day  or  year  of  other  illnesses  than  tuber- 
culosis is  presumably  greater,  and  also  the  cost  per  day  for 
other  classes  is  higher  than  for  the  poor."18  Applying  to 
the  three  million  and  more  persons  constantly  ill  in  the 
United  States  this  partial  annual  cost  to  public  institutions 


NATIONAL  HEALTH  PROBLEM  25 

of  $100  for  each  consumptive,  we  have  a  total  annual  loss 
for  public  care  of  $300,000,000. 

OTHER  ESTIMATES 

A  second  estimate  for  total  illness  expenses  to  the  con- 
sumptive poor,  set  at  $1.50  a  day  by  Dr.  Biggs  of  New 
York,  applied  to  the  three  million  persons  constantly  ill, 
gives  a  total  of  a  billion  and  a  half  dollars. 

Another  estimate  is  based  upon  an  investigation  by  the 
United  States  Department  of  Labor  of  five  thousand  work- 
ingmen's  families.  Their  average  expenditure  for  illness 
and  death  amounted  to  $27  a  year.  For  the  more  than 
eighteen  million  families  in  the  country  this  estimate,  more 
than  conservative  for  all  classes,  would  make  over  $486,- 
000,000.  The  three  estimates,  the  first  and  last  very  pains- 
takingly made,  are : 

$300,000,000  estimate  for  public  institutional  care  of 
sick. 

$500,000,000  estimate  for  total  cost  of  illness. 

$486,000,000  estimate  for  cost  to  all  families. 

The  first  and  last  give  only  very  partial  costs.  It  would 
seem,  then,  that  $500,000,000  would  be  a  very  conservative 
estimate  of  the  actual  cost  of  illness  care  for  the  people  of 
the  United  States  each  year. 

Adding  together,  finally,  the  capitalized  earning  power 
of  the  workers  dying  from  preventable  diseases  and  acci- 
dents each  year,  over  a  billion  dollars,  the  annual  idleness 
loss  enforced  by  serious  illness  of  over  five  hundred  million 
dollars,  and  the  cost  of  institutional  and  private  care  of 
the  sick  amounting  to  more  than  another  five  hundred  mil- 
lion dollars  and  we  have  a  total  annual  loss  to  this  country 
and  its  people  of  over  two  billion  dollars,  certainly  a  sum 
of  sufficient  proportions  to  warrant  the  most  serious  con- 
sideration of  public  health  measures  by  all  citizens. 

In  terms  of  direct  or  indirect  illhealth  losses  (some 
form  of  taxation)  it  means  for  each  family  a  loss  con- 
siderably over  a  hundred  dollars  a  year.  (For  eighteen 
million  families,  $m  each.)  And  this,  in  the  Fight  of 


26       SCHOOL  HEALTH  ADMINISTRATION 

the  Nearing  efficiency  wage  statistics,  means  about  twenty 
per  cent,  or  more,  of  the  median  family  income.  When 
a  majority  of  a  people,  already  near  or  below  a  satisfactory 
standard  of  living,  are  forced  to  throw  away  such  a  large 
proportion  of  their  meager  incomes  and  to  render  up  so 
many  victims  to  health  ignorance  we  evidently  have  a 
national  problem  which  should  receive  first  attention  and 
speedy  solution  everywhere. 

C.  Losses  Due  to  Minor  Ailments,  Physical  Defects, 
Undue  Fatigue,   and   Generally  Lowered  Efficiency 

The  morbidity  losses  above  computed  are  those  of  deaths 
and  relatively  acute  and  serious  illnesses.  These  are  all  that 
curative  medicine  has  to  any  considerable  extent  so  far 
recognized.  Modern  and  future  preventive  medicine  will 
look  more  and  more  to  incipient  and  beginning  diseases. 
The  vicious  sequences,  like  undue  fatigue,  then  "bad  cold," 
then  consumption,  and  finally  death,  are  entirely  too  frequent 
for  a  schooled  and  civilized  people.  Different  estimates 
by  competent  observers19  show  that  on  the  average  for  "well" 
persons  from  three  to  five  days  are  lost  each  year  because 
of  such  indispositions  as  indigestion,  sick  headache,  tooth- 
ache, neurasthenia,  and  bad  colds.02  That  most  of  these 
are  easily  preventable  losses  a  host  of  competent  witnesses 
give  assurance.  Doctor  Luther  H.  Gulick,  for  example, 
says  that  "something  like  nine-tenths  of  all  the  minor  ail- 
ments that  we  have,  and  which  constitute  the  chief  source 
of  decreasing  our  daily  efficiency,  could  be  removed  by 
careful  attention."  And  further,  "With  the  removal  of 
nine-tenths  of  our  disabilities  and  the  conservation  and 
further  development  of  our  natural  powers  the  average 
person  can  increase  his  efficiency  100  per  cent,  that  is, 
he  can  be  twice  as  effective.  This  does  not  refer  to  doing 
merely  or  mainly  twice  as  much  work,  of  course,  but  by 
making  less  mistakes,  and  by  working  at  a  higher  degree 
of  speed  when  he  does  his  work." 

We  shall  not  attempt  to  compute  in  financial  terms 
these  widespread  losses  of  efficiency  from  minor  ailments. 


NATIONAL   HEALTH   PROBLEM  27 

They  constitute  a  large  part  of  the  general  unnecessary 
health  losses  of  the  nation.  These  great  and  serious 
problems  of  the  nation  are  the  first  problems  of 
its  institutions.  In  the  case  of  the  health  problem 
we  have  a  universal  need  which,  because  of  its  foundation 
in  ignorance,  is  peculiarly  the  problem  of  the  public  school, 
the  fundamental  agency  of  social  improvement  and  reform. 
Legislative  changes  bringing  to  families  pure  water,  light, 
air  and  foods,  or  better  incomes  and  hours  of  labor,  or 
better  protection  from  disease  germs — all  these  wait  on  the 
generation  with  more  adequate  health  knowledge,  health 
habits,  and  health  responsiveness.  Better  health  knowledge, 
better  health  habits,  and  greater  sensitiveness  to  bad  health 
conditions  must  come  very  largely  with  the  children  from  the 
public  schools.  What  the  health  problem  means  to  the 
schools  themselves  let  us  now  inquire. 

Complete   references  at  end  of  Chapter  Two. 


CHAPTER  TWO 
THE   SCHOOL   HEALTH   PROBLEM 

PREVENTABLE   SCHOOL  LOSSES,   VITAL  AND  ECONOMIC 

/.  Death  Losses 

THE  death  losses  of  the  boys  and  girls  of  the  public 
schools,  are,  in  the  light  of  their  preventability,  appalling. 
The  1910  Mortality  Statistics  show  that  in  the  registration 
area  alone  a  total  of  about  fifty  thousand  children,  between 
the  ages  of  five  and  nineteen  inclusive,  died  during  the 
year.  Very  few  cities  in  the  United  States  give  separate 
statistics  of  the  deaths  of  school  children.  Children  elim- 
inated by  death  have  received  little  more  attention  or  study 
in  the  past  than  those  retarded  or  eliminated  by  illness  and 
other  causes.  So  neither  the  Census  Bureau  nor  the  Bureau 
of  Education  have  the  facts.  An  approximate  computation 
may,  however,  be  made. 

In  the  age  group,  5  to  9  years,  in  1910  there  died  in 
the  registration  area  17,943  children  (2.2  per  cent  of  all 
deaths)  ;  in  the  10  to  14  years'  group,  11,736  children  died 
(1.5  per  cent)  ;  and  in  the  15  to  19  years'  group  there  was 
a  death  loss  of  19,772,  or  2.5  per  cent  of  the  total  number 
of  deaths  of  all  ages.  (I  have  been  unable  to  get  the 
number  dying  at  each  year  of  life.)  For  the  5  to  14  years' 
group  the  total  is  approximately  thirty  thousand  (29,679)  ; 
and  for  the  5  to  19  years'  group  the  total  is  about  fifty  thou- 
sand (49,451).  Most  school  children  will,  of  course,  be 
found  in  the  first  group,  5  to  14,  although  many  will  be 
found  in  the  second  group  because  of  the  higher  deathrate, 
and  the  number  in  secondary  schools. 

28 


SCHOOL    HEALTH    PROBLEM 


29 


Calculated  as  was  the  total  number  of  deaths  in  the 
United  States,  we  find  that  the  deaths  between  the  ages  five 
and  nineteen  would  be  6.2  per  cent  (sum  of  the  above  per- 
centages) of  the  total  number  of  deaths  in  continental 
United  States  (1,600,000),  or  practically  a  hundred  thou- 
sand (99,200). 

Not  all  these  children  were  enrolled  school  children. 
Dr.  G.  D.  Strayer's  "Introductory  Survey"  to  the  1910 
report  of  the  Commissioner  of  Education  shows  that  in  the 
school  year,  1908-9,  more  than  seventy  (72.22)  per  cent 
of  the  children  between  the  ages  5  and  18  inclusive  were 
enrolled  in  the  "common  schools."  This  does  not,  how- 
ever, take  in  the  nineteen-year  group  included  above,  nor 
the  private  school  enrollment. 

72.22  per  cent  of  99,200  is  71,642.  Deducting  very 
liberally  for  the  nineteen-year  group,  by  methods  largely 
estimations,  we  should  say  that,  at  the  very  least,  65,000 
of  the  children  enrolled  in  the  public  schools  died  during 
the  calendar  year. 

TABLE    III. 

SHOWING  THE  PREVENTABILITY  OF  DEATHS   OP  CHILDREN  OF  ELEMEN- 
TARY   SCHOOL   AGE,    5-14,    FOR    25    MOST    NUMEROUS 
CAUSES  OF  DEATH,   1910 

No.  deaths         Per  cent 

in  regis- 
Causes  of  Deaths.  tration  area 

1.  Accidents     3,760 

2.  Diphtheria    and    croup 3,638 

3.  Scarlet    fever     2,173 

4.  Pneumonia     1,802 

5.  Heart,   organic   disease    1,727 

6.  Typhoid    fever     1,537 

7.  Tuberculosis    of     lungs 1,537 

8.  Tuberculosis,     other     1,519 

9.  Appendicitis      1,218 

10.  Meningitis      1,048 

11.  Measles      740 

12.  Rheumatism,    articular    684 

13.  Broncho-pneumonia      670 

14.  Diarrhea    and    enteritis 601 

15.  Bright's    disease,    kidneys 487 

16.  Endocarditis,    heart     429 

17.  Nephritis,    acute,    kidneys 418 

18.  Spinal   cord,   others    410 

19.  Diabetes      350 

20.  Tetanus,    lockjaw    315 

21.  Whooping    cough     245 

22.  Peritonitis      241 

23.  Intestinal    obstruction    215 

24.  Epilepsy      197 

25.  Influenza,    grippe    195 


Pre- 
ventable. 

70 
50 
45 
25 
85 
75 
75 
50 
70 
40 
10 
50 
60 
40 
25 
30 

io 

80 
40 
55 
25 


50 


Total  No. 
deaths 
in  the  U.  S. 
6,300 
6,200 
3,700 
3,050 
3,000 
2,600 
2,600 
2,560 
2,160 
1,600 
1,250 
1,150 
1,140 
1,020 

820 

730 

700 

690 

500 

530 

410 

400 

390 

330 

330 


No.  Pre- 
ventable 
deaths. 

4,340 

1,850 

1,370 

750 

2,210 

1,950 

1,920 

1,080 

1,120 

500 

116 

570 

612 

328 

182 

210 

"GO 

424 

164 

220 

97 


82 


26,227  67*  44,270**  20,155 

Total  number  of  deaths,  5-14,   in   registration  area,   29,679. 
Total  number  of  deaths,  5-14,    in   the  U.   S.,   about  50,000. 
Total    number    deaths    preventable,    about    33,500.      Based    upon    1910    U.    S. 
Mortality   Statistics    and   Fisher's   Preventability   Tables. 


'Fisher's   average. 


'Estimated. 


30      SCHOOL   HEALTH  ADMINISTRATION 


TABLE    IV. 

SHOWING     THE     PREVENTABILITY    OF    DEATHS    OF    CHILDREN 
SCHOOL  AGE,  15-19,  FOR  25  MOST  NUMEROUS  CAUSES 

OF     DEATH     IN  1910. 

No.  deaths  Per  cent           Total  No. 

in  regis-  Pre-  deaths 

Causes  of  Deaths.                   tration  area.  ventable.        in  the  U.  S. 

1.  Pulmonary  Tuberculosis    5,166  75  8,650 

2.  Accidents    and    undefined 2,525  ..  4,230 

3.  Typhoid    Fever    1,681  85  2,830 

4.  Heart    Disease,    Organic 1,158  25  1,940 

5.  Pneumonia     1,140  45  1,920 

6.  Tuberculosis,    other    parts 933  75  1,750 

7.  Appendicitis      754  50  1,270 

8.  Bright's    Disease     440  40  740 

9.  Suicide      326  .  .  550 

10.  Meningitis      294  70  500 

11.  Rheumatism,     Articular 261  10  450 

12.  Diabetes     258  10  450 

13.  Scarlet   Fever    232  50  400 

14.  Diphtheria    and    Croup 228  70  400 

15.  Nephritis,  Acute   199  30  340 

16.  Endocarditis    (Heart)     196  25  340 

17.  Epilepsy      172  .  .  300 

18.  Peritonitis      162  55  280 

19.  Broncho-pneumonia    158  50  280 

20.  Cancer  and  other  tumors 152  ..  260 

21.  Spinal  Cord,  other  Dis 130  ..  220 

22.  Influenza,    Grippe     119  50  200 

23.  Intestinal     Obstruction 117  25  200 

24.  Measles     112  40  190 

25.  Apoplexy,    Cerebro.    Hem 103  35  180 


*67 


28,780 


OF    HIGH 


No.  Pre- 
ventable 
deaths. 
6,487 

2,405 
485 
864 

1,177 
63f. 
296 

'356 

45 

45 

200 

280 

102 

85 

'l54 
140 


100 
50 
76 
63 

14,039 


17,016 

*Fisher's  average  for  all  causes  of  death. 

Total  number  of  Deaths,  15-19,  in  Registration  Area,   19,772. 
Total   number  of  Deaths,   15-19,  in  the  U.  S.   about  34,000. 
Total  number  of  Deaths,  15-19,  Preventable,  about  24,100.     Based  upon  1910 
U.  S.  Mortality  Statistics  and  Fisher's  Preventability  Tables. 

PREVENTABILITY,   AND   ECONOMIC    LOSS   TO   SCHOOLS    FROM 
DEATHS  OF  SCHOOL  CHILDREN 

Professor  Fisher's  ratio  of  preventability  for  childhood, 
with  the  median  years  2  to  8,  is  67  per  cent.  The  percent- 
age for  the  children  of  school  age  would  be  considerably 
higher,  not  only  because  of  the  good  means  of  social  control 
but  because  of  the  greater  bodily  resistance  and  consequent 
fewer  deaths  in  the  school  period  as  compared  with  those 
on  either  side,  older  or  younger.  Seventy  per  cent  would 
probably  be  a  very  low  estimate.  Seventy  per  cent  of 
65,000  is  over  forty-five  thousand  (45,500).  A  truer 
figure  would  probably  be  fifty  thousand.  For  an  entirely 
conservative  number  of  preventable  deaths  of  children  en- 
rolled in  the  public  schools  (not  counting  private  school 
children)  of  the  United  States,  let  us  take  forty  thousand 
(40,000).  This  is  the  annual  price  we  pay  in  the  deaths 
of  our  school  children  for  inadequate  health  measures.  The 
two  accompanying  tables  state  the  facts  concretely. 


SCHOOL    HEALTH    PROBLEM  31 

That  this  is  probably  a  very  conservative  number  future 
statistics  will  show.  Germany  and  Sweden  have  already 
cut  down  their  death  rate  for  the  school  ages  even  more 
than  this.21 

MONEY     LOSSES 

The  biggest  problem  of  the  public  schools  is  to  get 
sufficient  money  to  carry  on  their  work.  How  much  have 
the  schools  spent  in  educating  these  forty  thousand  children 
dying  of  preventable  deaths  in  any  one  year?  Multiplying 
the  average  per  capita  cost  of  public  schools  (enrollment 
basis)  of  about  $23,  by  this  number  (23  times  40,000) 
we  have  for  one  year  a  wasted  expenditure  of  $920,000, 
probably  in  all  about  a  million  dollars.  The  median  num- 
ber of  years  that  these  children  had  been  in  school  was 
probably  five.  This  would  make  a  total  annual  expenditure 
by  society  for  which  it  received  no  return  (in  educating 
pupils  who  die  during  school  age)  amounting  to  about 
five  million  dollars.  This  sum  is  exceeded  by  the  total 
annual  1909-10  school  expenditures  of  only  four  cities  in 
the  United  States. 

A  statistical  fallacy  probably  creeps  in  here  similar  to 
that  evident  in  the  calculated  enormous  economic  losses 
due  to  retardation  found  so  frequently  in  superintendents' 
reports  and  statistical  studies.22  The  cost  of  one  pupil 
one  year,  due  to  the  economic  law  of  diminishing  expense, 
cannot  rigidly  be  called  the  per  capita  expenditure,  perhaps. 
But  that  there  is  a  very  large  economic  loss  to  a  city  through 
educating  children  who  die  before  the  age  of  productivity, 
and  that  a  very  large  share  of  it  is  preventable  is  in- 
disputable. 

//.  Illness  Losses 

A.   THEIR  EXTENT 

As  in  the  case  of  actual  deaths  among  pupils,  very  few 
school  systems  keep  a  separate  record  of  absence  due  to 
illness,  and  so  the  actual  effect  of  illness  absences  as  well  as 
lowered  pupil  efficiency  upon  retardation  and  poor  school 


32      SCHOOL  HEALTH  ADMINISTRATION 

work  are  unsolved  problems.  The  amount  of  absence  due 
to  illness  is  enormous  and  can  partially  be  determined  by 
the  number  of  exclusions  for  contagious  diseases,  the  num- 
ber of  school  children,  both  ill  and  well,  quarantined  dur- 
ing the  school  year,  and  the  number  absent  voluntarily  be- 
cause of  illness  as  it  may  be  recorded  on  the  teachers'  record 
books.  That  at  least  50  per  cent  of  such  absence  is 
preventable  can  be  judged  from  the  ratio  of  preventability 
of  deaths  for  childhood  and  the  fact  that  much  of  this 
loss  is  due  to  minor  ailments  like  toothaches  and  colds. 

The  general  absence  from  all  causes  can  rather  accur- 
ately be  told.  Dr.  Strayer's  statistics  mentioned  above23 
show  that  the  "average  number  of  days  the  schools  were 
kept  during  the  year"  for  all  public  schools  in  the  United 
States  was  155.3,  while  the  "average  number  of  days  at- 
tendance by  each  pupil  enrolled"  was  only  112.6.  Although 
the  difference  of  43  days  does  not,  for  various  reasons,  ac- 
curately show  the  total  average  absence  by  pupils,  it  cer- 
tainly cannot  be  very  far  from  at  least  22  days  absence 
each,  an  average  attendance  of  85  per  cent.  City  schools 
alone  have  a  longer  school  year  and  better  attendance,  of 
course.  This  number  (22)  applied  to  the  total  number  of 
pupils  enrolled  in  1909-10,  17,506,175  (not  counting  the 
estimated  1,498,701  private  school  pupils)  gives  the  total 
number  of  days  lost  in  the  public  schools  of  the  United  States 
through  absence,  while  enrolled,  as  nearly  four  hundred 
million  (385,135,850). 

The  recent  Sage  Foundation  investigation  entitled  UA 
Comparative  Study  of  Public  School  Systems  in  the  Forty- 
eight  States,"  page  13,  shows  an  average  absence  ranging 
from  44.2  per  cent  in  Mississippi  to  12.2  per  cent  in  Oregon. 
The  question  is  as  to  the  amount  due  to  illness. 

Farr's  estimate,  used  by  Fisher,  of  two  persons  con- 
stantly seriously  ill  for  each  annual  death,  applied  to  the 
sixty-five  thousand  deaths  of  school  children  would  mean 
a  daily-absence  through  serious  illness  of  135,000  days,  or 
for  the  school  year  of  155  days,  20,925,000  days.  This 


SCHOOL    HEALTH    PROBLEM  33 

estimate  does  not  include  absences  for  minor  ailments  or 
physical  defects. 

THE  KEYES'  INVESTIGATION 

Dr.  Keyes'  study  of  the  "Progress  Through  the  Grades 
of  City  Schools"  gives  the  average  annual  amount  of 
absence  incurred  by  2,033  pupils  in  a  school  system  (Hart- 
ford, Conn.)  with  good  attendance,  as  ten  days  each,  or 
20,330  days  in  all.24  He  further  says  that  "this  loss  of 
time,  under  the  general  acceptance  and  rigid  enforcement 
in  the  community  of  the  laws  requiring  constant  attendance 
and  prohibiting  child  labor,  is  practically  a  measure  of  the 
amount  of  illness  in  all  grades  from  two  to  eight  inclusive." 
Applying  this  low  average  loss  of  ten  days  annually  to  the 
school  children  of  the  country,  we  have  an  illness  loss  of 
ten  times  eighteen  million  or  180,000,000  days,  about  nine 
times  the  estimate  given  above  for  serious  illnesses.  The 
attendance  laws  were  probably  very  much  better  enforced 
in  this  city  than  is  common,  and  fewer  children  were  out 
for  minor  illnesses  than  is  general. 

This  would  probably  make  the  illness  loss  to  the  great 
common  schools  of  the  country  something  like  two  hundred 
million  days  annually.  In  terms  of  school  years  of  155.3 
days  each  this  means  a  loss  of  schooling  equal  to  consider- 
ably over  a  million  school  years,  1,290,000.  This  might 
be  classed  as  wasted  or  ineffective  expenditure  at  $23  a 
year. 

Many  other  relatively  inaccurate  methods  of  computing 
illness  losses  might  be  used.  The  need  is  for  more  accurate 
and  more  general  records.  We  shall  leave  the  matter  with 
the  probably  conservative  estimate  of  an  average  of  two 
weeks  (ten  days)  for  each  child  in  the  public  schools  of 
the  country.  This  is  on  the  average  about  seven  per  cent 
of  the  time.  When  we  remember  how  few  days  of  school- 
ing in  their  lifetime  most  children  get  this  largely  prevent- 
able loss  due  to  illness  of  from  four  to  seven  per  cent  stands 
forth  in  all  its  enormity. 


34      SCHOOL   HEALTH   ADMINISTRATION 

B.  ILLNESS  LOSS  IN  RETARDATION,   ELIMINATION  AND  NON- 
PROMOTION 
I.   THE    PROBLEM 

Since  the  classic  studies  of  retardation  by  Thorndike,25 
Ayres26,  and  Strayer27  there  has  been  a  national  agitation 
over  this  matter.  Our  mass  education  has  made  necessary 
a  large  amount  of  repeating  of  grades.  Children  who  have 
not  been  able  to  keep  up  with  the  large  classes  have  been 
left  behind,  to  do  the  half  or  whole  year's  work  again. 
The  number  of  such  "repeaters"  in  any  school  system  is 
large.  For  the  United  States  as  a  whole,  the  number  of 
children  repeating  grades  each  semester  of  the  year,  is 
astounding  in  size.  The  number  of  whole  years  repeated 
in  any  one  year,  equivalent  to  the  same  number  of  children 
repeating  a  whole  year's  work,  must  be  considerably  over 
a  half  million  (6oo,ooo)28  or  about  two  or  three  pupils  to 
a  school  room,  the  country  over.  Almost  half  of  our  pupils 
are  above  "normal  age." 

Realizing  the  inaccuracy  of  all  such  figures  at  the  present 
time  let  us  raise  also  the  problem  of  the  effect  of  illness  on 
retardation.  There  are  at  least  three  ways  in  which  this 
retarding  effect  from  illness  is  felt:  the  retarding  influence 
of  absence,  especially  long  absence  due  to  a  contagious 
disease,  for  the  children  ill,  the  retarding  effect  on  those 
quarantined  or  otherwise  kept  out  of  school  by  other  school 
children's  quarantine  (those  in  the  same  house  or  family), 
and,  third,  the  effect  of  lowered  physical  vitality  due  to 
illness. 

A  few  school  superintendents  have  said  privately  that 
pupils  absent  from  illness  "grow  while  they  are  out  and 
generally  make  up  their  work  when  they  get  back  to  school." 
Dr.  Keyes'  study  of  the  actual,  yearly,  individual  records 
of  a  great  many  children  does  not  bear  out  this  opinion. 
He  shows  (page  54)  that  pupils  losing  more  time  than 
normal  pupils  have  also  more  arrests;  and  lose  very  much 
more  time  on  the  average  than  accelerates  or  honor  pupils. 
The  average  annual  loss  in  days  for  683  arrests  was  12.3 
days;  for  606  normals  10.2  days;  for  613  accelerates  still 


SCHOOL    HEALTH    PROBLEM  35 

less,  9.7  days;  and  for  131  honor  pupils  6.8  days,  about 
half  the  first  sum. 

For  the  longer  absences  (considered  as  practically  all 
due  to  illness)  we  have  the  same  showing.  The  per  cent 
of  children  losing  four  weeks  or  more  in  some  one  year 
is:  For  arrests,  76.6  per  cent;  for  normals,  68.4  per  cent; 
for  accelerates  66.6  per  cent;  and  for  honors,  45.3  per 
cent. 

In  table  28,  Dr.  Keyes  shows  the  surprisingly  close 
relationship  existing  between  the  number  of  days  school- 
ing lost  and  the  per  cent  of  arrests  during  the  year  of  loss. 
The  number  of  days  lost  increase  as  follows:  o,  5,  10,  15, 
20,  25,  30,  35,  40,  45,  50  or  more,  and  the  corresponding 
percentage  of  arrests  in  the  year  of  loss  increases  con- 
comitantly,  as  follows:  14,  15,  17,  23,  40,  48,  47,  48, 
51,  48,  72.  This  is  a  correlation  of  about  ninety  per  cent. 

According  to  this  detailed  study  of  the  individual,  cumu- 
lative record  cards  of  pupils,  at  least  twenty-five  per  cent 
of  all  pupils  are  retarded  when  they  are  absent  for  any 
length  of  time  less  than  a  month.  Absences  varying  from 
one  to  two  months  stay  the  progress  of  fifty  per  cent  of 
the  absentees;  and  when  the  loss  amounts  to  fifty  days  or 
more,  as  in  the  cases  of  serious  illness  or  long  quarantine, 
nearly  seventy-five  per  cent  of  all  pupils  sustaining  such  ab- 
sence fail  of  promotion. 

2.  DR.  BACHMAN'S  STUDY  OF  THE  RELATION  OF  ABSENCE 
TO  NON-PROMOTION 

In  his  investigation  entitled  "Report  Upon  Promotion, 
Non-Promotion  and  Part  Time"  as  a  part  of  the  recent 
New  York  City  school  inquiry,  and  distributed  about  the 
first  of  March,  1913,  Dr.  Frank  P.  Bachman  gives  the 
methods  and  results  (pages  63-70)  of  an  attempt  to  dis- 
cover the  relation  of  absence  from  school  to  non-promotion 
among  568,612  elementary  school  pupils  for  the  second 
term,  February  to  June,  1911.  Unfortunately,  late  entrance 
to  the  schools,  which  is  frequent  in  a  city  with  a  large 
floating  population  like  this,  could  not,  from  the  data  col- 


36      SCHOOL   HEALTH   ADMINISTRATION 

lected,  be  separated  from  irregularity  of  attendance.  The 
effect  of  such  late  entrance  can  be  estimated  from  the  data 
given  later  for  Boston,  where  650  of  the  8,496  cases  of 
non-promotion,  or  nearly  8  per  cent,  were  judged  to  be  due 
to  this  factor  alone. 

"Of  the  568,612  pupils  on  register  in  regular  classes 
June  30,  1911,"  he  says,  "382,406,  or  67.25  per  cent,  were 
absent  during  the  February- June  term,  1911,  ten  days  and 
less;  97,512,  or  17.15  per  cent,  eleven  to  twenty  days; 
39,391,  or  6.93  per  cent,  twenty-one  to  thirty  days;  19,297, 
or  3-39  Per  cent,  thirty-one  to  forty  days;  and  30,006,  or 
5.28  per  cent,  forty-one  days  and  above."  (Italics  mine  and 
used  only  to  distinguish.) 

The  following  tables  are  well  worth  study,  but  cannot 
be  given  here.  A  very  large  part  of  the  absence  is  in  the 
first  half  of  the  first  grade,  especially  for  long  absences. 
The  children  of  the  upper  grades  have  more  short  absences 
and  very  much  less  long  absences.  60.27  per  cent  of  the 
one  A  grade  were  absent  twenty  days  and  less  in  this  half 
year  and  the  percentage  gradually  rises  up  to  the  highest, 
eight  B  grade,  where  it  is  95.17.  The  average  is  84.4 
per  cent  for  all  grades.  But  for  the  long  absences  of  21 
days  or  more,  there  were  39.73  per  cent  of  the  lowest 
grade  and  only  4.83  per  cent  of  the  highest,  with  an  average 
of  15.6  per  cent  for  all  grades.  The  first  and  second  grades 
have  a  very  large  amount  of  long  absence,  while  the  seventh 
and  eighth  have  comparatively  very  little,  the  averages  be- 
ing 23.42  per  cent  and  8.21  per  cent. 

What  has  all  this  varying  and  extensive  absence  for  one 
term  to  do  with  the  rate  of  school  progress,  economy  of 
time,  retardation  and  non-promotion?  Dr.  Bachman  con- 
cludes: "Absence  is  a  very  large  factor  in  increasing  the 
number  of  non-promotions,  and  hence  in  increasing  con- 
gestion. With  the  exception  of  the  lA  grade,  absence 
affected  more  seriously  the  rate  of  promotion  in  the  higher 
than  in  the  lower  grades;  and,  in  all  grades,  the  rate  of 
promotion  varies  inversely  with  the  amount  of  absence." 
(Page  70.) 


SCHOOL    HEALTH    PROBLEM  37 

The  average  rate  of  promotion  for  pupils  absent  20 
days  and  less  he  finds  was  92.03  per  cent;  for  those  absent 
more  than  20  days  the  rate  was  only  70.57  per  cent;  a 
difference  of  21.46  per  cent. 

Dr.  Bachman  does  not  work  out  the  chances  of  failure 
in  different  grades  for  the  varying  amounts  of  absence,  but 
a  good  deal  of  light  is  thrown  on  the  problem;  and  his  dif- 
ferences by  grades  in  rates  of  promotion  for  those  above 
20  and  those  below  21,  and  his  table  showing  the  uPer  Cent 
of  Decrease  in  Non-Promotions  at  Rate  of  Promotion  for 
Pupils  Absent  From  Zero  to  Ten  Days"  (an  average  of 
64.3  per  cent)  are  good  substitutes. 

All  these  amounts  of  absence  should  be  multiplied  by 
two  to  approximate  the  annual  loss  in  days  for 'this  city 
that  year. 

We  see  here  that  there  is  a  close  correlation  of  amount 
of  absence  with  the  chances  of  non-promotion,  and  so  of 
retardation.  All  we  should  need  to  do  would  be  to  find 
this  numerically  for  grades  and  amounts  of  time  lost,  and 
then  the  part  which  ill-health  played  in  causing  this  absence, 
in  order  to  isolate  and  define  the  force  of  this  health  factor. 
Other  factors  than  absence  enter  in,  of  course,  but  it  will 
not  be  an  impossible  problem  to  compute  for  a  given  system 
or  for  many  what  the  chances  are  that  a  child  in  a  given 
grade  has  to  pass  for  various  amounts  of  absence  from 
school. 

3.    THE    TEACHERS-REPORTS    METHOD 

Another  method  of  investigating  the  causal  relationship 
between  illness  and  retardation  is  to  have  teachers  state  the 
cause  of  each  case  of  failure  of  promotion.  A  number  of 
school  superintendents  have  used  this  method  in  the  last 
two  years.  Great  care  must  be  taken  in  using  it,  for  the 
judgments  of  teachers  frequently  are  wrong  in  these  mat- 
ters and  plurality  and  composition  of  causes  come  in  to 
complicate  the  question.  However,  they  do  point  toward 
the  relative  force  of  different  retarding  factors. 

THE    HOBOKEN   STUDY 

Superintendent  A.  J.  Demarest,  of  Hoboken,  found  that 


3 8      SCHOOL   HEALTH   ADMINISTRATION 

19  per  cent  of  the  pupils  of  the  schools  had  failed  of  pro- 
motion in  February,  1911.  A  study  of  the  probable  causes 
of  1706  of  these  failures  gave  the  following: 

Pupils 

1.  Irregular  attendance;  sickness  one  of  the  causes..     297 

2.  Quarantine   of   pupils    14 

3.  Personal  illness    65 

4.  Poor  school  work  by  pupils  and  teachers,  transfers, 

substitutes,    etc 1,066 

5.  Foreigners,  and  ignorance  of  the  English  language    100 

6.  Late  entrance  into  school  for  various  reasons 91 

7.  Truancy    3 

8.  Physical    defects:      nervous    troubles,     adenoids, 

tonsils,  vision,  etc 28 

9.  Early  entrance,  too  young  for  school  work 19 

10.  Sluggish  mentality  and  mental  defects 23 

Total   1,706 

Personal  illness  alone  (2  and  3)  seems  to  account  for 
less  than  five  per  cent  of  the  cases  of  retardation.  We 
should,  however,  have  to  pick  out  from  the  first,  fourth, 
sixth  and  tenth  groups  those  others  whom  illness  quite 
largely  made  fail.  This  would  raise  the  percentage  prob- 
ably to  10  per  cent. 

THE  BOSTON  NON-PROMOTION  STUDY 

Boson  made  a  study  of  this  serious  problem  for  the 
pupils  failing  of  promotion  for  the  half  year  ending  June, 
1910  (School  Document  14,  1910,  page  26).  "The  sum- 
mary of  these  returns,  which  follows,  is  of  great  interest  as 
revealing  the  real  causes  for  retardation  based  upon  an 
actual  and  individual  investigation  of  a  large  number  of 
cases  for  a  definite  and  specific  period."  This  judgment  of 
the  school  committee  is,  of  course,  unsound,  for  a  number 
of  serious  causes  of  non-promotion,  and  so  of  retardation, 
are  not  here  listed.  It  would  be  very  interesting,  indeed, 
to  take  up  just  one  other  cause  of  non-promotion  along 
health  lines.  What  effect  has  the  absence  of  teachers  due 
to  illness  (not  their  inefficiency,  but  the  relative  inefficiency 


SCHOOL    HEALTH    PROBLEM  39 

of  the  substitutes  and  changes  incident  thereto)  have  upon 
the  amount  of  non-promotion?  The  amount  of  such  ab- 
sence among  women  teachers  of  most  school  systems  is 
enormous  and  easily  ascertained.  In  general,  does  the  num- 
ber of  failures  of  the  children  increase  with  the  amount  of 
absence  of  their  teachers? 

"In  June,  1910,  the  total  registration  in  the  elementary 
grades  was  809,908.  Out  of  this  number,  10.5  per  cent 
(8,496)  were  retarded,  i.e.,  not  permitted  to  progress  to 
the  next  grade  on  the  opening  of  school  in  September,  1910. 
A  blank  form  was  sent  to  each  principal  requesting  him 
to  state  the  reason  why  each  child  in  this  group  (8,496) 
had  not  been  promoted.  The  following  is  a  summary  of 
the  replies  received: 
Illness  (diphtheria,  scarlet  fever, measles,  surgery,  etc.)  .1,252 

Mentally  deficient    369 

Defective  vision    241 

Defective  hearing    83 

Defective  speech 53 

Deformities    31 

Adenoids    13 

Nervous    7 

Total  2,049 

Mentally  immature  (slow  mental  development) 2,803 

Entered  late  in  the  school  year 650 

Lazy 538 

Inattentive    495 

Absence  caused  by  truancy,  neglect,  home  work 468 

Came  from  other  schools 405 

Came  recently  from  foreign  countries 331 

Promoted  on  trial  at  beginning  of  year 239 

Causes  unknown 196 

Repeated  change  of  schools 181 

Miscellaneous    127 

Cigarette  smokers   14 

Total    8,496 


40      SCHOOL   HEALTH   ADMINISTRATION 

No  account  is  taken  here  of  plurality  or  composition 
of  causes  and  it  seems  remarkable  that  teachers  could  say 
so  definitely  that  just  one  thing  caused  a  pupil's  failure 
of  promotion,  when  undoubtedly  in  perhaps  a  majority  of 
cases  several  causes  contributed  to  the  failures.  As  we  have 
arranged  the  items  of  the  table,  the  first  eight  items  are 
clearly  within  the  scope  of  medical  inspection,  with  the  pos- 
sible exception  of  "mentally  deficient."  Until  separate 
divisions  of  psychology  are  formed,  however,  and  then  only 
in  very  large  school  systems,  we  have  the  item  rightly 
placed.  Cigarette  smokers  are  reported  by  many  nurses 
as  a  part  of  their  regular  duties  and  a  number  of  other  items 
not  among  the  eight  were  more  or  less  matters  of  ill-health 
and  physical  defects  but  could  not  be  ascertained  by  the 
teachers.  The  large  nursing  staff  of  the  schools  was  set 
to  work  to  improve  the  health  conditions  of  these  delayed 
children,  with  what  results  I  have  not  learned. 

These  eight  reported  causes  applied  to  2,049  children 
of  the  8,496.  This  is  nearly  twenty-five  per  cent  (25%). 
Bringing  in  the  other  health  factors  in  other  items  of  the  list, 
we  should  probably  have  much  over  30  per  cent. 

If  we  were  to  take  the  judgments  of  the  teachers  and 
principals  of  the  elementary  schools  of  Boston  at  their 
face  value,  we  should  have  to  say  that  over  one-fourth  of 
all  retardation  in  the  elementary  schools  is  due  to  some  form 
of  ill-health.  But  much  of  this  was  undoubtedly  due  to  the 
inefficiency  of  the  teachers  and  their  substitutes,  to  a  poorly 
adapted  curriculum,  to  lack  of  proper  administrative 
measures  for  getting  pupils  to  school  and  inciting  their  max- 
imum efforts,  to  bad  home  conditions  preventing  opportunity 
for  study,  to  lack  of  ventilation  and  adequate  play  and 
energizing  facilities,  etc.,  etc.  However,  it  does  show  that 
in  the  opinion  of  these  persons,  and  what  is  undoubtedly 
true,  ill-health,  physical  defects,  deformities,  lowered  vital 
efficiency,  and  the  like,  do  have  a  serious  retarding  influence 
and  prevent  efficient  economy  of  time  in  education. 
THE  MT.  VERNON  STUDY 

Supt.  Edwin  C.  Broome,  of  Mt.  Vernon,  N.  Y.,  in  his 


SCHOOL   HEALTH    PROBLEM  41 

1911  report,  pages  35-38,  gives  the  results  of  a  study  made 
with  the  help  of  principals  and  teachers  of  the  causes  of 
the  non-promotion  of  562  pupils  in  June,  1911.  The  teach- 
ers were  asked  to  give  the  probable  causes  of  the  failure 
of  their  pupils.  They  did  not,  of  course,  list  poor  teaching 
as  a  cause;  neither  did  they  mention  the  absences  of  teach- 
ers, when  pupils  were  in  the  not  too-efficient  hands  of 
substitutes.  There  were  707  causes  given  for  the  non- 
promotion  of  562  pupils  that  term,  so  more  than  one  cause 
was  given  for  several  pupils.  The  table  is  as  follows: 
Reasons  assigned  Cases 

1.  Irregular  attendance  or  late  entrance  to 

class 158 —  22.3% 

2.  Lack  of  physical  vitality 18 —     2.5% 

3.  Mental  dullness   133 —  19.0% 

4.  Mentally  deficient,  or  abnormal 30 —     4.2% 

5.  Physical  defects    14 —     2.0% 

6.  Immaturity  (applies  to  lowest  grades)  .  .  96 —  13.4% 

7.  Below  grade,  or  conditioned,  at  entrance 

to  class 125 —  17.7% 

8.  Inability  to  use  English 28 —     3.1% 

9.  Inattention,  carelessness,  indolence 83 —  13.3% 

10.  Miscellaneous    22 —     2.5% 

Total    707 — 100    % 

We  can  only  guess  at  the  amount  of  the  irregular  at- 
tendance which  was  due  to  illness,  quarantine,  exclusion  by 
doctors  and  nurses,  and  the  like.  Absence  is  a  big  causal 
factor  and  illness  is  a  factor  lying  back  of  much  of  this. 
A  large  part  of  the  first  five  items  would  come  under  the 
head  of  bad  health  conditions.  The  smallness  of  the  phy- 
sical defects  item  may  well  be  questioned  because  the  city 
did  not  have  physical  examinations  of  the  pupils  adequately 
to  locate  the  defects,  only  inspection.  A  large  number  of 
cases  of  inattention,  carelessness  and  indolence  may  have 
been  due  to  such  undiscovered  defects.  If  we  could  say 
that  probably  at  least  50  children  were  retarded  because  of 
illness  alone  this  term,  we  should  have  a  proportion  of 
nearly  ten  per  cent.  This  can  be  only  an  estimate,  of  course. 


42      SCHOOL   HEALTH   ADMINISTRATION 

THE   TRENTON   STUDY 

Superintendent  Ebenezer  Mackey,  of  Trenton,  N.  J.,  in 
his  1911  report,  shows,  first,  the  causes  of  elimination  from 
school,  second,  of  non-promotion,  and,  third,  of  retardation, 
according  to  this  method.  Of  2,218  pupils  who  left  school 
and  did  not  return  ("eliminated"),  the  following  causes 
come  within  our  perview: 

CAUSES  OF  ELIMINATIONS 

Withdrew  because  of  poor  health 192,  or     8.7% 

Withdrew  because  of  sickness  in  the  family     33,  or     1.5% 

Withdrew  because  of  physical  defects 9,  or       .4% 

Withdrew  because  of  death 22,  or     1.0% 


n.6% 

CAUSES   OF    NON-PROMOTIONS 

There  were  8,394  pupils  promoted  during  the  year  and 
1,943  not  promoted,  1,055  °f  whom  are  called  repeaters. 
1,918  causes  are  given  for  these  1,055  repeaters.  The  fol- 
lowing are  the  causes  which  concern  us  here: 

1.  Ill-health    122,  or    6.3%  of  the  causes 

2.  Physical  defects 68,  or    3.5%  of  the  causes 

3.  Dull    369,  or  19.3%  of  the  causes 

4.  Irregular  attendance    340,  or  17.7%  of  the  causes 

5.  Absent  at  time  of  promotion.  109,  or    5.6%  of  the  causes 

6.  Immaturity    (mostly    in    the 

first  3  years) 133,  or    6.8%  of  the  causes 

These  six  of  the  twenty-one  causes  given  are  either 
directly  connected  with  ill-health  or  should  be  studied 
further  from  the  health  standpoint.  Undoubtedly  back  of 
several  of  these  factors  ill-health  stands  out  in  some  way 
as  a  determining  cause.  There  were  physical  examinations 
made  of  most  of  the  elementary  children  in  this  city,  so  the 
percentage  for  physical  defects  must  be  based  upon  more 
definite  knowledge  than  in  Mt.  Vernon,  where  they  made 
up  less  than  two  per  cent  of  the  causes  given.  If  teachers 
had  more  accurate  knowledge  of  the  health  conditions  of 
their  children  this  factor  would  probably  be  raised.  As 


SCHOOL    HEALTH    PROBLEM  43 

it  is,  ill-health  makes  up  6.3  per  cent  of  the  factors  given. 
Further  analysis  would  probably  show  that  ill-health  alone 
was  the  cause  in  about  8  or  10  per  cent  of  the  cases.  We 
need  further  studies  along  these  lines. 

Besides  studying  elimination  and  non-promotion  Super- 
intendent Mackey  gives,  third,  the  causes  of  retardation, 
i.e.,  of  all  the  pupils  who  are  below  the  grades  they  should 
normally  be  in  at  their  respective  ages.  For  4,184  pupils 
in  the  elementary  schools  who  were  above  normal  age  for 
their  grades,  the  following  excuses  or  reasons,  among  ten 
given,  are  offered,  page  93  (3,682  mentions  of  the  10 
causes)  : 

1.  Sickness .  .257,  or    7.0%  of  the  causes 

2.  Physical  defects 219,  or    6.0%  of  the  causes 

3.  Irregular  attendance 550,  or  15.0%  of  the  causes 

4.  Lack  of  ability 406,  or  11.1%  of  the  causes 

5.  Lack  of  application 453,  or  12.3%  of  the  causes 

All  of  the  last  three  mentioned  causes  may  refer  to 
pupils  many  of  whom  have  an  ill-health  basis  for  their  poor 
attendance,  ability  or  application.  Sickness  is  at  about 
the  same  percentage  as  previously  given. 

Data  from  many  other  cities  might  be  offered.  For  want 
of  space  and  time,  and  because  of  their  relative  inaccuracy, 
we  must  be  content  with  these  few.  Until  we  have  more 
careful  health  records  of  children,  we  can  only  guess  at  the 
influence  of  illness  on  school  progress. 

4.    GATHERING-THE-FACTS    METHOD 

Another  method  used  by  superintendents  of  schools 
eliminates  personal  judgments  quite  largely,  but  still  leaves 
the  difficulty  of  separating  combinations  of  causes. 

THE    SOUTH   MANCHESTER   STUDY 

Superintendent  F.  A.  Verplanck,  of  South  Manchester, 
Conn.,  in  his  1911  report  (see  also  1912  report,  pages  12 
to  17)  gives  the  results  of  a  study  of  elimination  and  non- 
promotion,  based  upon  the  records  of  the  pupils  kept  by 
the  schools.  Of  188  pupils  eliminated  from  the  schools, 


44      SCHOOL   HEALTH  ADMINISTRATION 

ill-health  and  death  were  the  causes  of  17  and  4  respectively, 
together  making  a  percentage  of  11.2  per  cent. 

Two  hundred  forty-one  pupils,  or  17.4%,  were  not  pro- 
moted. Of  this  he  writes:  "I  am  confident  that  the  figures 
would  have  been  still  better  had  it  not  been  for  the  pre- 
valence of  contagious  disease,  which  seriously  interfered 
with  the  attendance." 

The  attendance  factor  is  shown  by  comparing  the  aver- 
age number  of  days  attended  by  those  promoted  and  those 
not  promoted.  The  schools  were  in  session  186  days,  and 
the  promoted  pupils  lost  on  the  average  32  days,  while  the 
non-promoted  pupils  lost  52  days,  a  difference  of  four 
weeks,  a  month  in  favor  of  the  promoted  pupils.  A  very 
large  part  of  this  low  attendance  of  all  was  due  to  the 
epidemics  of  diphtheria,  scarlet  fever,  and  measles,  and 
other  forms  of  illness.  How  much  we  cannot  say. 

The  physical  defects  causes  given  in  the  report  will  be 
offered  under  that  heading  later. 

ATTENDANCE  OFFICERS'  REPORTS 

Another  way  to  get  at  the  amount  of  absence  due  to 
ill-health  is  through  the  reports  of  attendance  officers,  given 
in  many  superintendents' reports,  but  in  only  a  few  adequately 
analyzing  the  causes  of  non-attendance.  In  South  Man- 
chester, 755  absentees  were  looked  up,  with  the  following 
results  of  interest  to  us  here: 

Causes  of  Absences  from  School,  for  755  Pupils. 

Personal  illness 305,  or  40.4% 

Illness  in  the  family 57,  or     7.8% 


362,  or  48.0% 

Here  we  have  a  proportion  of  almost  50  per  cent  due, 
according  to  the  officer's  statement,  to  ill-health.  We  have 
shown  that  there  is  a  close  correlation  between  absence  and 
failure  of  promotion.  What  percentage  of  the  cases  of 
non-promotion  in  South  Manchester  were  due  to  the  vari- 
ous ill-health  factors  such  as  exclusions  by  medical  officers, 
quarantine  of  pupils  ill  and  only  exposed,  actual  personal 


SCHOOL    HEALTH    PROBLEM  45 

illness,  and  illness  in  the  family  which  makes  necessary 
an  older  child's  help  at  home  or  the  younger  ones  to  stay 
at  home  "because  mother  was  sick  and  could  not  get  them 
ready,"  we  cannot  say.  The  writer's  personal  judgment 
based  upon  the  tables  given  and  other  factors  in  the  situa- 
tion places  it  at  nearly  20  per  cent  of  the  non-promoted 
pupils.  There  was  probably,  however,  an  abnormally  large 
amount  of  infectious  disease  in  this  city  during  the  year. 

THE  SCHENECTADY  TABLE 

In  the  Schenectady  report  for  1911  Superintendent  A. 
R.  Brubacher  gives  a  table,  page  53,  which  potentially  might 
throw  some  light  on  this  problem.  Unfortunately  only  facts 
for  unpromoted  pupils  are  given,  without  a  control  class, 
or  the  possibility  of  comparing  the  data  with  promoted 
pupils,  so  we  can  draw  no  satisfactory  conclusions.  The 
total  registration  was  11,074,  of  whom  385  failed  outright 
and  263  failed  on  condition,  648  in  all. 

For  these  pupils,  all  in  the  elementary  schools,  we  are 
given  the  following  facts: 

Defective  sight 58 

Defective  hearing   43 

Absences : 

Because  of  sickness   457 

Because  of  quarantine 34 

Unexcused    99 

Absence  of  20  or  more  days 113 

These  facts  are  interesting  here,  but  to  derive  from  them 
any  conclusions  we  should  have  to  have  the  six  items  of 
data  for  at  least  the  number  of: 

Pupils   promoted  unconditionally. 
Pupils  failing,  with  a  condition. 
Pupils  failing  unconditionally. 
To  which  might  well  be  added  the  same  data  for 

Pupils  promoted,  but  with  a  condition. 
It  is  probably  true  that  these  figures  show  abnormal  con- 
ditions for  retarded  children  in  the  direction  of  ill-health. 
It  is  significant  that   113  of  the  648  pupils  were  absent  a 


46      SCHOOL   HEALTH   ADMINISTRATION 

month  or  more  (whether  of  one  of  the  two  groups  or 
the  other,  or  of  both,  and  in  what  proportions,  we  do  not 
know),  which,  according  to  Keyes,  would  tend  to  fail  over 
50  per  cent  of  the  number. 

5.    QUARANTINE    ABSENCE    AND    RETARDATION 

Another  way  of  studying  the  effect  of  ill-health  is  to  take 
the  children  who  have  been  quarantined  and  see  what  their 
chances  of  promotion  are  in  comparison  with  other  chil- 
dren. No  person  has  yet  attempted  such  a  study  so  far 
as  the  writer  is  aware. 

Absence  due  to  quarantine  is  given  in  a  number  of  cities. 
Newark  in  the  1911  report  furnishes  the  following  strik- 
ing data: 

Absence   due   to  quarantine 56,517  days 

Total  absence  due  to  all  causes 1,055,560  days 

Total  attendance  of  all  pupils 8,890,974  days 

Here  we  see  that  the  attendance  is  only  eight  or  nine 
times  the  amount  of  absence,  and  that  quarantine  absence 
makes  up  over  5.3  per  cent  of  the  total  amount  of  absence. 
The  average  length  of  quarantine  for  1,892  pupils  given 
separate  mention  was  over  21  days  each. 

If  statistics  were  gathered  regarding  these  quarantined 
pupils  in  any  city  and  their  promotions  much  light  could 
easily  be  thrown  on  the  problem. 

6.  EXCLUSION  ABSENCE  AND  RETARDATION 

Many  pupils  are  excluded  by  physicians  and  nurses  who 
are  not  quarantined.  The  number  of  days  lost  is  frequently 
reported.  Thus  in  Philadelphia  the  exclusions  for  different 
ailments  caused  an  average  loss  ranging  from  favus  with 
60  days,  or  12  school  weeks,  and  chorea  with  an  average 
loss  of  57  days,  over  n  weeks,  down  to  exclusions  for  lack 
of  cleanliness  of  one  day  and  pediculosis  with  an  average 
of  three  days.  The  average  loss  for  each  ailment  was 
(1910  report  of  Board  of  Health)  17  days,  or  over  three 
weeks. 

In  the  Hoboken  1911  report  we  find  that  383  pupils 
lost  by  exclusions  4105  days,  an  average  of  nearly  n 


SCHOOL    HEALTH    PROBLEM  47 

days,  or  over  two  weeks,  each.    We  cannot  obtain  the  medi- 
an, but  we  see  how  serious  exclusions  are. 

These  figures  show  not  only  what  a  great  factor  in  ab- 
sence ill-health  is,  but  point  out  new  fields  for  the  investiga- 
tion of  this  serious  problem  of  health  in  the  schools  and 
homes. 

NEED  OF  RIGOROUS  INDUCTIVE  METHODS 

Each  of  these  problems  must  be  solved  through  inten- 
sive and  extensive  investigation  and  by  persons  skilled  in 
inductive  thinking  and  the  technique  of  discovery  in  educa- 
tional fields.  There  are  very  many  difficulties  and  pitfalls 
of  which  the  general  administrator  or  investigator  is  un- 
aware. It  may  happen,  for  example,  that  the  illness  ab- 
sentees are  a  selected  group  who  became  ill  because  of 
general  hereditary  or  sociological  causes,  and  that  these,  not 
so  much  the  absence,  are  the  cause  of  poor  school  work. 
Practically  all  the  fallacies  of  inductive  thinking  lie  before 
each  one  who  adds  to  the  science  of  education,  and  the 
school  health  problem  seems  to  be  peculiarly  infested  with 
them. 

SUMMARY   FOR   ILLNESS    LOSSES 

In  summing  up  the  case  for  illness  we  can  give  a  general 
quantitative  statement  of  its  effect  upon  elimination,  non- 
promotion  and  retardation  in  only  the  most  hypothetical 
way.  Our  purpose  has  been  accomplished  if  the  tremend- 
ous importance  of  this  source  of  waste  in  education  has 
been  adequately  emphasized,  and  the  necessity  for  serious, 
technical  investigations  of  its  causes  and  prevention  in  each 
school  system  has  been  shown  desirable. 

Such  study  will  probably  show  that  illness  in  one  form 
or  another,  directly  or  indirectly,  but  not  including  physical 
defects,  is  responsible,  as  a  single  factor,  for  nearly  twenty- 
five  per  cent  of  absences  from  school,  for  ten  to  fifteen 
per  cent  of  the  elimination,  for  ten  to  twelve  per  cent  of 
non-promotion,  each  term,  and  for  at  least  ten  per  cent  of 
retardation. 


48      SCHOOL  HEALTH  ADMINISTRATION 

///.  School  Losses  Due  to  Physical  Defects,  and  Lowered 
Vital  Efficiency 

A  little  more  study  has  been  made  of  the  effects  of 
physical  defects  upon  school  progress.  Dr.  L.  P.  Ayres 
summarizes  these  in  the  1913  edition  of  his  book  on  "The 
Medical  Inspection  of  Schools,"  Chapter  II.  In  his  book 
on  "Laggards  in  Our  Schools,"  Dr.  Ayres  develops  statistic- 
ally the  conclusion  that  "in  general  children  suffering  from 
physical  defects  are  found  to  make  8.8  per  cent  less  progress 
than  do  children  having  no  physical  defects." 

Serious  strictures  are  made  by  Dr.  W.  S.  Cornell  in 
his  book  on  "Health  and  Medical  Inspection  of  School 
Children,"  pages  387  to  391,  on  the  Ayres'  findings,  and 
by  the  writer  in  a  later  chapter,  enough,  perhaps,  entirely 
to  invalidate  the  quantitative  conclusions;  but  of  one  thing 
we  are  sure,  that  physical  defects  do  have  a  serious  influ- 
ence upon  school  efficiency  and  school  progress,  exactly  how 
much  we  can,  at  present,  only  estimate. 

DR.  WALLIN'S  STUDY 

A  very  technical  study  by  Prof.  J.  E.  W.  Wallin,  on  the 
relation  of  oral  hygiene  to  mentality,  reinforces  to  some 
extent  these  conclusions.  A  squad  of  27  school  children  in 
Cleveland,  O.,  were  given  free  dental  treatment  and  hygienic 
instruction — filling  of  cavities,  cleaning  of  gums,  instruc- 
tion in  the  care  of  teeth,  "fletcherizing"  of  food,  etc. — 
and  before,  during,  and  from  three  to  five  months  after 
this  treatment  were  given  a  series  of  five  mental  tests  to 
determine  whether  or  not  the  remedy  of  these  physical 
defects  had  produced  a  corresponding  increase  in  mental 
power. 

"In  spite  of  much  individual  variation,  the  results  showed 
a  decided  gain  in  every  test.  The  best  proof  of  the  benefit, 
and  therefore  of  the  importance  of  the  work,  is  that,  al- 
though all  the  members  of  the  squad  were  laggards  of  from 
one  to  four  years,  only  one  failed  of  promotion  in  the  term 
immediately  following  the  treatment.  The  beneficial  effect 
on  general  health  of  the  children  was  noticeable  to  chil- 


SCHOOL    HEALTH    PROBLEM  49 

dren,  parents,  and  teachers  alike."  (Dental  Cosmos  for 
April  and  May,  1912.  Article  on  "Experimental  Oral 
Euthenics.") 

The  collusiveness  of  this  elaborate  investigation  is  lost, 
however,  because  no  control  squad  of  pupils  was  used.  If 
another  like  class  had  been  given  the  same  treatment  with 
the  single  exception  of  the  oral  hygiene  treatment  and  in- 
struction and  real  differences  found,  we  might  suspect  the 
truth  of  the  conclusion  that  there  is  such  causal  relationship. 
We  may  reasonably  suppose,  however,  that  had  any  group 
of  retardates  such  as  these  been  selected  and  given  special 
attention  reaching  into  the  homes  with  the  help  of  nurses, 
with  money  rewards,  with  special  testing  by  principal  and 
-physician,  and  with  a  small  class  for  the  teacher — had  any 
similar  class  been  given  all  this  attention  with  no  attention 
to  mouth  hygiene,  or  with  the  emphasis  on  some  other 
factor,  say  deep  breathing,  or  removal  of  enlarged  tonsils 
and  adenoids,  or  open-window  classroom,  or  personal 
courtesy  even,  nearly,  if  not  quite,  the  same  results  might 
have  been  obtained.  That  "during  the  experimental  year 
only  one  of  the  27  pupils  failed  of  promotion,"  is  not  sur- 
prising, regardless  of  the  oral  hygiene.  Pragmatically,  such 
findings  do  good  in  getting  a  proper  emphasis  on  certain 
features  of  health  provision  by  school  officials  and  others. 
How  much  is  fact,  and  how  much  is  the  fallacies  of  plur- 
ality and  composition  of  causes  no  one  knows.  We  may 
demonstrate  that  "on  the  whole  .  .  .  the  average  child 
improved  about  50  per  cent  in  all  the  tests  during  the  ex- 
perimental year,"  but,  as  the  writer  points  out,  there  w'as 
a  "paramount  need  of  testing  such  a  parallel  group,"  and 
"our  knowledge  in  this  field  is  largely  pretense,  sham, 
illusion." 

SUPERINTENDENTS'  METHODS 

Another  method  of  getting  an  idea  of  the  effect  of  phy- 
sical defects  on  school  progress  and  elimination  is  the 
teacher-report  and  studying-the-facts  methods  described 
above  under  illness  effects.  Looking  back  over  these  and  a 


50      SCHOOL   HEALTH   ADMINISTRATION 

number  of  other  such  studies  we  can  draw  the  following 
very  tentative  hypotheses: 

Physical  defects  are  probably  causal  factors  in  about  the 
following  proportions  among  other  causes: 

Five  per  cent  of  eliminations  from  school; 

Six  per  cent  of  non-promotion; 

Seven  or  more  per  cent  of  retardation. 
A  pupil  may,   of  course,  miss  promotion  and  still  be 
young  for  his  class,  and,  so,  not  retarded.     It  is  the  per- 
sistent "repeaters"  who  make  up  a  large  portion  of  the  re- 
tarded. 

IF.  Summary  of  Chapters  One  and  Two 
The  problems  of  life  furnish  the  problems  of  education, 
and  one  of  the  most  important  of  these  is  that  of  good 
health.  No  serious  and  extended  attempt  has  previously 
been  made  by  school  officials  to  discover  in  a  comprehensive 
manner  the  nature  and  the  importance  of  this  problem  of 
the  nation  and  of  the  schools. 

NATIONAL    LOSSES 

The  national  health  losses  are  those  of  preventable 
deaths,  preventable  serious  illness,  and  preventable  minor 
ailments  and  defects. 

Approximately  1,600,000  people  in  the  United  States 
die  each  year,  or  nearly  two  per  cent  of  our  population. 
Our  most  reliable  computations,  derived  from  life  insur- 
ance records  and  health  experts'  estimates,  indicate  that 
probably  670,000  of  these  deaths,  or  42  per  cent,  are 
reasonably  preventable.  Conservative  and  carefully  cal- 
culated estimates  of  the  national  economic  losses  due  to  these 
preventable  deaths  indicate  an  annual  loss  of  over  a  billion 
dollars. 

There  are  approximately  three  million  persons  seriously 
ill  at  all  times  in  the  United  States.  The  chief  national 
illness  losses  computable  are  those  of  lost  wages  and  private 
and  public  care  of  the  sick.  These  two  forms  of  economic 
loss,  very  largely  preventable,  each  amount  to  about  five 
hundred  million  dollars  annually. 


SCHOOL    HEALTH    PROBLEM  51 

Combined,  we  have  a  largely  preventable  economic  loss 
in  deaths  and  in  illness  amounting  to  two  billion  dollars  an- 
nually, a  sum  great  enough  to  cover  the  land  with  preven- 
tive agencies. 

Added  to  these  losses  are  those  due  to  minor  ailments, 
physical  defects,  and  lowered  vital  efficiency,  largely  pre- 
ventable. These  aihnents  help  to  lower  the  working 
efficiency,  cause  much  absence  from  daily  employment,  and 
are  a  serious  source  of  expense  to  a  large  proportion  of 
our  population.  Any  study  of  the  attendance  of  teachers 
in  the  schools,  of  workers  in  the  factories  and  stores,  or  of 
day  laborers,  will  point  to  enormous  losses  in  these  fields, 
decreasing  national  wealth  and  increasing  race  degeneracy. 
SCHOOL  LOSSES 

The  principal  school  losses  are  in  the  form  of  deaths 
of  school  children,  educated  for  a  number  of  years  and 
dying  before  the  age  of  productivity,  illness  losses,  and  losses 
due  to  physical  defects  and  lowered  vital  efficiency.  Much 
can  be  done  on  this  side  of  eugenics  in  eliminating  these 
school  losses. 

Nearly  a  hundred  thousand  children  of  school  age  die 
in  this  country  each  year.  Strayer's  government  report 
makes  possible  an  estimate  of  6^,000  deaths  of  enrolled 
public  school  children  each  year.  No  estimate  is  made  for 
those  in  private  schools,  but  the  number  is  probably  near 
five  thousand.  Fisher's  estimate  of  preventability  of  the 
deaths  of  children  makes  possible  an  estimate  of  an  annual 
unnecessary  death  loss  of  over  40,000  public  school  chil- 
dren. This  is  only  part  of  the  price  we  pay  for  inadequate 
health  measures  in  home,  school,  community  and  nation. 
The  socially  ineffective  school  expenditures  for  the  educa- 
tion of  children  who  die  before  the  age  of  productivity  are 
enormous  but,  as  yet,  uncomputed.  Generous  health  meas- 
ures in  schools  may  well  be  justified  on  this  basis  alone. 

The  illness  losses  to  the  schools  are  for  both  teachers 
and  children,  but  only  those  for  the  latter  are  studied.* 

*  Professor  Terman  has  made  an  investigation  of  the  former  in  a 
book  entitled  "The  Teacher's  Health,"  Houghton,  Mifflin  Co. 


52      SCHOOL  HEALTH  ADMINISTRATION 

These  illness  losses  come  in  the  form  of  economic  losses 
to  the  school  and  in  personal  losses  through  elimination, 
non-promotion,  retardation,  and  lowered  vital  and  school 
efficiency.  The  chief  outward  result  of  school  illness  is 
that  of  non-attendance,  and  the  effect  of  such  absence  has 
been  studied  in  a  number  of  ways,  several  of  which  are 
given,  but  none  of  which  are  conclusive.  Tentative  sug- 
gestions are  reached  that  illness  is  the  chief  or  only  factor 
in  perhaps  10  to  15  per  cent  of  elimination  from  school, 
10  or  12  per  cent  of  non-promotion  each  term,  and  at  least 
10  per  cent  of  retardation.  Beyond  this,  many  pupils  do 
poor  work  and  barely  pass  from  term  to  term  because  of 
lowered  vitality  due  to  illness  past  or  present. 

The  school  losses  due  to  physical  defects  have  also  been 
problems  of  a  number  of  investigations,  but  none  of  these 
arrives  at  a  quantitative  statement  which  warrants  belief. 
The  whole  problem  is  open  for  investigation.  That  the 
losses  are  large  and  serious  seems  quite  evident.  Physical 
defects  are  probably  the  chief  or  only  factors  in  about  five 
per  cent  of  the  elimination  from  school,  six  per  cent  of 
non-promotion,  and  seven  per  cent  of  retardation.  Careful 
studies  will  probably  raise  these  tentative  estimates,  made 
here  only  for  the  purpose  of  emphasizing  these  health 
problems  as  an  introduction  to  the  later  chapters.  The 
lowered  vital  efficiency  due  to  physical  defects  of  the  pupils 
who  barely  pass  with  very  low  standards  from  term  to  term 
must  also  be  considered  in  this  problem. 

Since  illness  and  physical  defects  frequently  go  together, 
their  combination  in  any  one  pupil  or  pupils  offers  a  very 
serious  menace  to  school  efficiency,  probably  causing,  as 
combined  factors,  almost  fifteen  per  cent  of  elimination,  six- 
teen per  cent  of  non-promotion,  and  seventeen  per  cent  of 
retardation.  When  we  consider  the  enormous  proportion 
of  the  twenty  million  school  children  who  fall  into  one  or 
more  of  these  classes,  according  to  the  best  estimates,  the 
school  health  problem  stands  out  as  one  of  the  acute 
problems  of  modern  life. 

The  following    chapters    will    attempt    to    show    what 


SCHOOL  HEALTH  PROBLEM  53 

American  cities  are  doing  for  the  health  of  the  children  and 
the  nation;  what  twenty-five  cities  are  doing  in  detail  with 
critical  consideration  of  their  efforts;  and,  finally,  what 
probably  can  be  done  in  the  administration  of  educational 
hygiene  along  more  effective  and  economical  lines. 

REFERENCES 

1.  Beyer,  Popular  Science  Monthly,  February,  1912. 

2.  Ditman,  "Education  and  its  Economic  Value  in  the  Field  of  Pre- 

ventive Medicine,"  Columbia  University  Press. 

3.  Fisher,   "National  Vitality"  in  Report  of  the  National  Conserva- 

tion Commission,   Senate   Document   No.  676. 

4.  Flexner,  "Bulletin  4,"  Carnegie  Foundation. 

5.  Terman,  "Professional  Training  for  Child  Hygiene,"  Popular  Sci- 

ence Monthly,  March,   1912. 

6.  National  Vitality,  page  736. 

7.  Durand,  Census  Bureau,  1910  Mortality  Statistics. 

8.  Bruere,  in  Harper's  Magazine  for  April,  1912. 

9.  Page  8,  Mortality  Statistics. 

10.  Page  10,  Mortality  Statistics. 

11.  Quoted  in  National  Vitality,  page  741. 

12.  National  Vitality,  Chapters  I  and  II. 

13.  National  Vitality,  page  728. 

14.  Annual  Report. 

15.  Journal  of  Outdoor  Life,  March,   1912. 

16.  National  Vitality,  page  741. 

17.  Popular  Science  Monthly,  March,   1912. 

1 8.  Biggs,  National  Vitality,  page  741. 

19  and  20.     National  Vitality,  Chapter  III. 

21.  Fisher,  in  private  letter. 

22.  Ayres,  "Laggards  in  Our  Schools,"   1913  edition  of  "Medical  In- 

spection of  Schools,"  and  bulletin  on  the  Money  Cost  of  Repeti- 
tion; and  Elson,  Cleveland,  1912  Report,  and  many  other  in- 
vestigators. 

23.  Strayer,   Bureau  of  Education  bulletin  No.  451. 

24.  Keyes'    Doctor's   Dissertation,    "Progress   through   the   Grades   of 

City  Schools,"  Columbia  University  Contributions  to  Education. 

25.  Bureau  of  Education  bulletin  No.  4,  1907,  and  articles  in  Psycho- 

logical Clinic,  Jan.  and  Feb.,  1910. 

26.  Ayres,   "Laggards  in  Our  Schools." 

27.  Strayer,  Bureau  of  Education  bulletin  No.  451. 

28.  Ditto. 


CHAPTER  THREE 

HOW  THE  HEALTH  PROBLEM  IS  BEING  MET  IN 
SCHOOLS  AND  NATION 

I.    PUBLIC    HEALTH    PROVISIONS 

THE  emergence  of  the  health  problem  as  one  of  serious 
national  importance  is  of  recent  date.  In  these  few  open- 
ing years  of  the  twentieth  century  the  gradual  increase  of 
health  needs  and  health  knowledge  has  flowered  forth  in 
what  one  writer  terms  "the  renaissance  of  the  physical 
conscience  of  the  race,"1  after  lying  dormant  since  the  time 
of  Pericles.  Why  health  has  for  so  long  been  a  matter  of 
relative  unconcern;  why  a  fatalistic  attitude  not  only  toward 
plagues,  sweeping  off  millions  of  people,2  but  toward  sick- 
ness and  high  death-rates  in  general,  has  been  maintained, 
is  not  easily  explained.  This  attitude  of  the  race  in  its 
long  health-middle-ages,  stands  out,  however,  in  remark- 
able contrast  both  to  that  of  the  Greeks,  health  as  a  religion, 
and  that  of  the  present,  health  as  a  science.  The  reverent 
teaching  and  practice  of  sound  life  and  normal  physical 
development  in  Athens;  the  ignorant  asceticism  and  plagues 
of  the  later  periods;  and  the  discovery  of  the  causes  of 
disease  and  early  death  with  the  growing  ideal  of  health 
as  an  individual  and  public  duty — these  are  the  three  ages 
of  Health.  The  great  number  of  years  does  not  adequately 
express  the  gaps  existing  betwteen  the  Olympic  games  with 
Hygieia;  the  Black  Death  with  Simon  Stylites;  and  the 
present  when  a  German  or  American  soldier  is  punished  for 
getting  an  increasing  number  of  diseases  and  Colonel  Gorgas 
is  scientifically  overcoming  death  at  Panama.3 

Among  the  explanations  must  be,  of  course,  the  general 

54 


MEETING   THE    HEALTH    PROBLEM       55 

causes  of  the  dark  ages;  theologic  asceticism;  the  poverty 
of  the  masses  which  made  life  cheap  and  perhaps  most 
additions  to  the  living  undesired;  the  tremendous  general 
ignorance,  especially  of  health  rriatters;  the  open,  relatively 
healthful  life  of  an  agricultural  people;  and  the  general 
individualistic  form  of  life  and  government.  The  marvel- 
lously rapid  change  in  public  opinion  and  practice  with 
regard  to  health  matters  is  due  quite  largely  to  the  in- 
dustrial revolution  with  its  development  of  factory  life, 
congested  business  cities,  and  dependent  poverty;  to  the 
transformation  of  preventive  and  curative  medicine  and 
sanitation  into  relatively  exact  sciences ;  the  growth  of  demo- 
cracy and  the  altruistic  conscience;  the  consequent  rise  of 
public  health  agencies;4  the  better  conditions  for  adequate 
social  control  of  health  and  disease,  especially  in  cities;  the 
great  increase  of  wealth  in  the  hands  of  a  few  and  the 
accompanying  possibilities  of  health  philanthropy  (e.g.,  the 
Rockefeller  Foundations,  the  Sage  Bureau  of  Child  Hy- 
giene, the  Forsythe  Dental  Dispensary  at  Boston,  and  many 
other  private  health  charities,  educational,  preventive  and 
curative)  ;  the  increase  in  the  organs  of  public  opinion  and 
the  increased  attention  of  newspapers  and  magazines  to 
public  health  instruction;  and,  finally,  and  fundamentally, 
the  growth  of  the  public  school  system  in  recent  years  with 
its  unparalleled  opportunity  for  health  control  of  the 
younger  generations  and  their  education  as  to  how  to  live 
healthily,  happily,  and  efficiently  in  the  modern  world. 
DEVELOPMENT  OF  GENERAL  HEALTH  AGENCIES 
This  universal  health  awakening  in  progressive  nations 
can  be  admirably  illustrated  by  the  recent  rise  and  rapid 
growth  of  public  and  private  organizations  for  the  promo- 
tion of  more  universal  health.  A  plotted  curve  of  such 
growth  in  its  entirety  would  show  little  rise  since  the  timies 
of  Harvey  and  Jenner  until  about  the  third  quarter  of  the 
past  century,  when  it  would  rise  abruptly  and  continuously 
and  have  a  still  sharper  ascent  in  these  opening  years  of 
the  twentieth  century.  The  first  rapid  rise  shows,  quite 
largely,  the  acquisition  of  health  knowledge;  the  second  the 


56      SCHOOL  HEALTH  ADMINISTRATION 

increasing  application  of  such  knowledge.  Public  and  per- 
sonal hygiene,  in  its  practice,  is  yet  several  decades  behind 
the  health  knowledge  held  by  the  few.5  President  Butler's 
terse  and  accurate  statement  of  the  situation  from  the  school 
point  of  view,  well  expresses  general  conditions:  "It  is 
not  too  much  to  say  that  health,  its  preservation  and  de- 
velopment, is  all-controlling  in  present-day  educational 
theory,  although  it  is  unfortunately  far  from  being  so  in 
practice.  The  chief  reason  for  this  discrepancy  between  the 
ideal  and  the  real  is  simple  ignorance."6 

To  make  private  science  public  health  knowledge  and 
practice,  is  the  mission  of  a  great  number  of  new  agencies, 
often  starting  as  private  bodies  and  gradually  becoming 
public  institutions,  according  to  a  rather  universal  method 
of  social  evolution.  Among  such  private  bodies  are:  The 
International  Congresses  on  School  Hygiene  beginning  in 
1904  at  Neuremberg;  the  American  Medical  Association; 
the  health  foundations  endowed  by  Rockefeller,  Sage,  Car- 
negie and  others;  the  Playground  Association  of  America, 
beginning  in  1907;  social  settlements  and  Christian  associa- 
tions everywhere;  the  Congresses  of  Sanitary  Engineers; 
the  Committee  of  One  Hundred  on  National  Vitality;  the 
National  Associations  for  the  Study  and  Prevention  of 
Tuberculosis,  for  the  Conservation  of  Vision,  for  Sanitary 
and  Moral  Prophylaxis,  for  the  Study  and  Prevention  of 
Infant  Mortality,  for  the  Study  of  the  Feeble  Minded;  the 
National  School  Hygiene  Association;  the  National  Con- 
sumers League,  the  National  Child  Labor  Committee,  the 
New  York  and  other  bureaus  of  municipal  research,7  the 
National  Educational  Association  to  same  extent  since 
1900;  tenement  house  commissions,  and  various  health 
magazines  and  general  magazines  with  health  articles  and 
departments.  These  and  a  great  many  other  organizations 
in  this  country  and  abroad  are  either  directly  or  indirectly 
working  for  public  health.* 

*G.  Stanley  Hall  gives  a  list  of  ninety  and  more  in  his  "Educational 
Problems,"  chapters  XI  and  XII. 


MEETING    THE    HEALTH    PROBLEM       57 

One  of  the  most  interesting  developments  has  been  the 
efforts  of  life  insurance  companies  to  keep  down  the  death 
rate  of  their  policyholders.  Certain  companies8  distribute 
free  literature  on  various  phases  of  the  preservation  of 
health,  hire  visiting  nurses,  and  give  free  annual  medical 
examinations  to  policyholders.  The  Lubin  Vitagraph  Com- 
pany has  even  dramatized  the  idea  and  is  sending  over 
the  world  films  portraying  an  insurance  president  saving 
his  company  from  paying  a  big  death  loss  at  a  financial 
crisis  by  sending  at  some  expense  a  bankrupt  family  South 
to  restore  the  father's  health,  and  brought  to  such  an  atti- 
tude by  the  naive  request  of  the  sick  man's  little  boy:  "We 
want  the  money  to  make  father  well  now;  we  won't  need 
it  when  he  gets  well." 

Some  of  the  other  public  health  movements  and  agencies 
are :  the  municipal,  county  and  state  Boards  of  Health  with 
their  rapidly  enlarging  scope  and  powers,  the  latter  now 
more  extensive  than  those  of  any  other  division  of  the  public 
service  not  excepting  the  police;  the  Boards  of  Education, 
in  response  to  the  needs  of  the  times,  similarly  widening 
their  community  service;  the  United  States  Department  of 
Labor  with  its  mortality  census  bulletins  from  the  Bureau 
of  the  Census  and  other  health  studies  in  the  field  of  labor; 
the  Department  of  Agriculture,  working  almost  entirely  in 
the  past  for  the  health  of  domestic  animals  rather  than 
the  people;  the  Bureau  of  Education,  which  has  as  yet  con- 
tributed very  little  to  public  health;  and  the  United  States 
Public  Health  and  Marine  Hospital  Bureau,  and  several 
others  which,  inevitably,  will  be  united  into  one  compre- 
hensive National  Department  of  Health  for  the  more 
organized  and  energetic  development  of  health  conditions 
in  the  entire  country,  similar  to  the  work  of  the  Depart- 
ment of  Agriculture  for  the  health  of  live-stock. 

There  has  recently  been  established  also  the  Children's 
Bureau  and  placed  in  the  Department  of  Labor.  What  is 
much  needed  is  a  great  increase  in  the  scope  and  support 
of  the  Bureau  of  Education,  corresponding  somewhat  with 
present-day  needs  and  present-day  ability  in  promoting 


58      SCHOOL  HEALTH  ADMINISTRATION 

child  welfare.  Following  the  rapid  development  of  many 
private  and  public  instrumentalities  for  health  promotion, 
a  correlating  movement  is  setting  in  which  will  help  to 
systematize  and  make  more  efficient  the  multitudinous  scat- 
tered efforts.  In  America  we  have  yet  a  long  way  to  go 
in  health  provisions  to  equal  the  splendid  work  which  Ger- 
many and  Sweden  have  been  doing  for  a  number  of  years. 
(Dr.  Irving  Fisher  says  in  a  private  letter:  "Sweden,  which 
has  made  the  greatest  progress  in  Hygiene  of  any  country, 
is  believed  to  have  done  so  largely  because  of  the  medical 
investigations  of  its  schools.") 

II.    SCHOOL    PROVISIONS    FOR    PUBLIC    HEALTH 

While  the  health  movement  is  but  beginning  in  the  schools 
very  much  has  already  been  accomplished  in  this  country 
and  elsewhere.  We  shall  not  stop  here  to  review  the  move- 
ment abroad  as  this  has  ably  been  done  in  a  number  of 
books  and  articles.9  It  seems  desirable  to  preface  the 
special  detailed  investigation  of  what  school  systems  are 
doing  for  public  health  in  a  limited  number  of  cities,  with 
a  brief  general  statement  of  some  of  the  more  prominent 
features  of  this  recent  movement  in  the  schools  of  our  own 
country. 

This  investigation  began  with  a  study  of  data  gathered 
by  the  Child  Hygiene  Bureau  of  the  Sage  Foundation  under 
the  direction  of  Dr.  Leonard  P.  Ayres  in  the  fall  of  1910. 
A  number  of  investigations  into  this  problem  then  beginning 
were  thus  correlated  into  one  comprehensive  investigation 
which  would  give  a  bird's-eye  view  of  the  field  and  the 
general  aspects  of  the  movement  in  the  schools.  The  fol- 
lowing questionnaire  was  printed  on  a  return  postal  card 
and  sent  to  every  superintendent  in  the  country  (1285  in 
all),  and  after  a  second  request  was  made  of  a  number, 
returns  were  received  from  1038  graded  school  systems: 


Date 

Have  you  a  system  of  medical  inspection? 

Year  work  was  begun    

Does  system  cover  inspection  for  contagious  diseases? 

f 


MEETING   THE    HEALTH    PROBLEM       59 

Are  vision  and  hearing  tests  made  by  teachers? 
Are  vision  and  hearing  tests  made  by  doctors? 
Is  there  full  physical  examination  by  doctors? 

Is   medical   inspection   administered   by   Board  of    Health   or   Board   of 
Education? 

Number  of  school  doctors Annual  salary 

Number  of  school  nurses Annual  salary 

Have  you  dental  inspection? Is  it  by  dentists? 

Do  elementary  children  have  regular  outdoor  recesses? 

Are  recesses  given  in  all  elementary  grades? 

How  many  schools  are  supplied  with  individual  drinking  cups? 

How  many  schools   have   sanitary  drinking   fountains? 

Are  moist  cloths  used  for  dusting? 

Are  dust  absorbing  compounds  used  for  sweeping? 

How  many  schools  have  vacuum  cleaning  outfits? 

How  often  are  classroom  windows  washed? 

How  often  are  classroom  floors  swept? 

How  often  are  classroom  floors  washed? 

Are  adjustable  desks  in  general  use? 

How  often  are  they  adjusted? 

Do  pupils   receive  special  instruction  on  alcohol   and  tobacco? 

Do  pupils  receive  special  instruction  on  tuberculosis? 

Do  pupils  receive  special  instruction  on  first   aid  to  injured? 

Name    

Place   

The  disadvantages  of  getting  facts  by  such  means  is  well 
known  and  has  been  further  discovered  through  visits  by 
the  writer  to  a  number  of  the  towns  replying  and  checking 
up  reports.  Nevertheless,  for  a  general  view  such  as  this 
and  covering  the  entire  country,  it  is  the  best  that  can 
be  done  in  a  short  time  and  at  reasonable  expense;  and 
probably  gives  a  fairly  correct  general  notion  of  the  present 
status  of  the  health  movement  in  the  schools.10  Some  of 
the  main  facts  discovered  by  this  investigation  are  here 
summarized: 

1.  Of  the    1038  cities  reporting  443,   or  43   per  cent,  had  medical 
inspection  of  some  kind. 

2.  The  very  rapid  growth  of  medical  inspection  since  1890  is  shown 
by  the  following  series,  giving  the  number  of  cities  having  medi- 
cal inspection  systems  for  each  year  (duplications  where  figures 
are  not  known  or  there  were  no  additions)  :  I,  I,  I,  I,  4,  4,  4,  5, 
8,  9,  n,  17,  23,  28,  37,  55,  77,  m,  167,  263,  400,  443.     In  1900 
eleven  cities  had  such  inspection;  in   1905  there  were  55.     The 
very  rapid  increase  has  been  since  then.     Probably  at  this  writing 


60      SCHOOL  HEALTH  ADMINISTRATION 

not  far  from  half  of  the  cities  of  the  country   are  attempting 
this   work. 

3.  In  443  cities  reporting  on  this  item,  336  had  the  work  admin- 
istered by  Boards  of  Education  and  106  by  Boards  of  Health. 
Formerly  this  work  was  all  done  by  the  Boards  of  Health  but 
by  state  law  and  municipal  agitation  the  work  is  being  trans- 
ferred to   Boards  of  Education   and   given  a  larger  educational 
purpose.  Not  only  inspection  for  contagious  diseases,  but  careful 
physical  examinations  once   a  year,   follow-up  work,   treatment, 
prevention,  and  cure  are  being  developed. 

4.  405,  or  39  per  cent,  of  the  443  cities,  report  inspection  for  con- 
tagious diseases.     It  is  probably  correct  to  say  that  practically 
all  cities,  however,  look  out  for  contagious  diseases  by  inspection. 

5.  "In  no  fewer  than  552  cities  vision  and  hearing  tests  are  con- 
ducted by  teachers,  and  in  addition  the  work  is  carried  on  by 
doctors  in  258  cities."     The  tendency  is  for  this  work,  required 
by  law  in  certain  states,  to  go  into  the  hands  of  the  school  nurses. 
As  practically  applied  a  single  teacher  in  a  school  has  generally 
made  these  tests.     The  nurse  or  physical  training  teacher  saves 
the  regular  teacher's  time  by  doing  such  work. 

6.  Of  the  443  cities  reporting  medical  inspection  systems  214,  about 
half,  have  thorough  examinations  by  doctors.     The  annual  physi- 
cal examination  of  every  child,  teacher  and  janitor  in  the  school 
system  by  specially  trained  nurses  and  doctors  will  probably  soon 
become  an  integral  part  of  all  health  work  in  the  schools.     Life 
insurance   companies   are  now  beginning   to   offer    free   medical 
examinations  to  save  the  lives  of  their  policyholders.     The  State 
has  a  greater  interest  than  any  private  group  in  the  health  of 
its  people. 

7.  The  returns  showed  that  there  were  1415  school  physicians  and 
415   school  nurses  employed.     While  both  are  sure  to  increase 
rapidly  in  numbers  it  is  the  opinion  of  the  writer  that  the  ratio 
of  three  to  one  will  shift  in  the  direction  of  one  to  three,  because 
of  the  greater  value  of  the  nurse's  work  in  getting  cures.     Doc- 
tors will  probably  make  the  more  technical  parts  of  the  annual 
physical  examination;  nurses  will  assist  in  this  and  make  inspec- 
tions and  follow-up  cases.      An  increasing  number  of  cities  have 
nurses  without  doctors. 

8.  Decayed  teeth  is  the  great  "people's  disease"  and  are  the  source 
of  perhaps  most  ailments.  At  least  fifty  per  cent  of  school  children 
suffer  from  this  malady.     Only  69  cities  have  dental  inspection 
by  dentists.    The  number  is  rapidly  increasing,  however,  and  free 
dental  treatment  is  bound  to  become  as  common  as  free  text-books 
and  free  schools  once  fought  as  "socialistic." 

9.  Medical   supervision   of  schools,   like  most   other   improvements 
and  the  very  schools  themselves,  has  grown  quite  largely  out  of 
private   efforts.     We,  therefore,  find   75  doctors   and  21   nurses 
receiving  no  pay  from  the  schools.    From  this  the  salaries  increase 
to  four  thousand  dollars  for  one  physician  and  fifteen  hundred 


MEETING   THE    HEALTH    PROBLEM       61 

dollars  for  two  nurses.  The  median  salary  for  nurses  is  about 
$70  a  month  and  for  doctors  about  $35.  Of  course,  the  nurse 
gives  five  to  forty  times  as  many  hours  a  week  as  the  physician 
in  most  cities. 

HYGIENE  OF  THE  SCHOOL  ROOM. 

10.  Of  the  1038  cities  reporting  947  or  about  91  per  cent  have  out- 
door recesses.  There  is  a  bad  tendency  the  other  way  in  north- 
eastern United  States. 

^  n.  264  or  about  25  per  cent  of  the  cities  are  abolishing  the  common 
drinking  cup  in  the  schools  by  the  use  of  individual  cups,  and 
in  785,  or  about  75  per  cent,  by  the  installation  of  sanitary  drink- 
ing fountains.  Cheap,  durable,  hygienic  and  easily  workable  types 
of  such  fountains  are  being  developed  and  they  will  undoubtedly 
become  as  common  as  blackboards  in  our  schools. 

12.  In  643,  or  over  60  per  cent,  of  the  cities  the  old  feather  duster 
or  dust  creator,  is  being  displaced  by  the  damp  cloth.  Unfor- 
tunately the  latter  requires  more  effort  and  constant  vigilance 
is  needed  to  keep  up  the  standard. 

13-  894,  or  about  90  per  cent,  of  the  cities  reported  the  use  of  dust- 
absorbing  compounds  for  sweeping.  Scientific  tests  are  much 
needed  in  this  field.  The  writer  has  seen  ten  cent  oil  work  better 
under  scientific  control  than  two-dollar  oil,  sold  to  unsuspecting 
but  health  loving  school  boards. 

14.  Cleanliness  is  perhaps  the  greatest  health  virtue.     Eleven  cities 
report   the   daily!  washing  of   school    floors   and   the   frequency 
ranges  down  to   51   cities   reporting  never.     The  latter   attempt 
to  clean  the  floors  with  oil,  not  an  impossibility.     Once  a  month 
to  once  in  three  months  seems  to  be  the  most  common  frequency. 

15.  The  frequency  of  floor  sweeping  gives  813  cities  reporting  daily, 
70  once  in  three  days,  and  106  once  in  four  days.     From  these 
it  ranges  off  to  one  city  reporting  "once  in  two  months."     Daily 
sweeping  when  there  are  eighty  or  more  little  feet  in  and  out 
of  a  single  room  all  day  seems  to  be  none  too  often. 

16.  The  washing  of  windows  varies  from  "weekly"  to  "never."    The 
mode  is  near  once  in  three  months. 

17.  428  cities  report  the  use  of  adjustable  desks,  about  41  per  cent. 
They  are   adjusted   very  uniformly.     One  city  reports   a  daily 
adjustment,  13  once  a  year.     The  modes  seem  to  be  "as  needed" 
and  once  in  five  months,  each  term. 

x  18.  As  to  instruction  in  hygiene,  95  per  cent  (982)  of  the  cities 
report  the  teaching  of  the  effects  of  alcohol  and  tobacco;  63  per 
cent  (649)  help  the  children  to  understand  and  to  combat  the 
great  white  plague  of  tuberculosis;  and  57  per  cent  (592)  give 
occasional  lessons  on  first  aid  to  the  injured. 

Had  we  the  same  statistics  in  each  case  for  ten  years 
ago  with  which  to  compare  each  of  these  items,  remarkable 
improvement  would  undoubtedly  be  shown  along  most  lines. 


62      SCHOOL  HEALTH  ADMINISTRATION 

Any  detailed  and  rigorous  investigation  of  particular  cities 
would  show,  however,  very  much  yet  to  be  accomplished 
before  the  schools  are  practicing  existing  health  science. 
STATE  LAWS  RELATING  TO  MEDICAL  INSPECTION 

Through  state  legislation,  great  advance  in  the  work 
of  medical  inspection  has  recently  been  fostered.  Other 
phases  of  educational  hygiene  have  also  been  improved  but 
we  shall  give  here  only  the  main  facts  regarding  this  newest 
phase  of  hygiene. 

According  to  Ay  res,11  the  first  state  law  on  medical  in- 
spection is  credited  to  Connecticut  (1899)  and  provided  for 
sight  and  hearing  tests  by  teachers.  New  Jersey  stands 
first  for  an  all-round  scheme  of  medical  inspection  in  the 
law  of  1903.  This  act  was  permissive,  however.  Massa- 
chusetts again  stands  at  the  head,  as  having  the  first  com- 
pulsory medical  inspection  law,  in  1906.  No  state  has  yet 
(1913)  a  state  supervisor  of  educational  hygiene. 

Up  to  May,  1911,  seven  states  had  mandatory  laws; 
ten  had  permissive  ones;  and  in  two  states  and  the  District 
of  Columbia  "medical  inspection  is  carried  on  under  regula- 
tions promulgated  by  the  boards  of  health  and  having  the 
force  of  law."  This  legislation  has  nearly  all  come  about 
in  the  last  five  years,  an  evidence  of  the  very  rapid  growth 
of  the  movement,  and  likewise  of  the  spread  of  public 
opinion  in  a  democracy.  Much  of  this  legislation,  like  the 
Massachusetts  law  of  1906,  will  need  to  be  amended  many 
times  as  the  movement  grows.  One  prominent  physician, 
for  example,  writes  from  a  Massachusetts  town,  "We  are 
compelled  by  law  to  employ  a  physician  as  medical  inspector 
but  we  have  experimentally  proved  the  nurse-alone  plan 
best."  With  such  a  physician  for  consultation  it  is  quite 
probable  that  specially  trained  school  nurses  may  do  most 
of  the  work,  and  the  law  will  need  amending  to  cover  this 
development  if  it  is  generally  followed. 

From  Dr.  Ayres'  pamphlet  previously  mentioned  the 
following  table  giving  the  principal  features  of  state  laws 
and  regulations  providing  for  medical  inspection  has  been 
taken,  with  the  author's  kind  permission.  The  five  states 


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64      SCHOOL  HEALTH  ADMINISTRATION 

covered  by  the  investigation  set  forth  in  the  following 
chapter  are  placed  at  the  head  of  the  list  for  easy  reference. 
The  tendency  toward  mandatory  legislation  in  this  mat- 
ter is  worth  noticing,  as  is  also  the  uniformity  of  opinion 
that  the  Board  of  Education  should  have  charge  of  it.  State 
supervision,  encouragement,  and  correlation  are  bound  to 
come  not  only  for  medical  inspection,  but  for  all  five  divi- 
sions of  school  health  provisions. 

THE  PLAYGROUND  MOVEMENT 

Recent  statistics12  show  the  same  forward  movement  of 
supervised  playgrounds.  There  are  at  least  332  cities  main- 
taining supervised  playgrounds.  The  257  cities  reporting, 
employed  during  the  year  ending  November  I,  1911,  4132 
men  and  women  exclusive  of  caretakers  on  1,543  play- 
grounds, and  expended  for  the  work  $2,736,506.16. 
Thirty-six  cities  employed  377  workers  all  the  year  round. 
In  39  of  the  257  cities  the  playgrounds  were  administered 
by  school  boards.  This  movement,  also,  is  only  about  five 
years  old. 

in.  CONCLUSIONS 

In  preceding  chapters  we  have  attempted  to  learn  the 
magnitude  of  the  national  and  school  health  problem.  This 
chapter  is  the  by-product  of  an  effort  to  determine  how 
adequately  the  present  national  and  school  health  agencies 
measure  up  to  the  health  needs.  Many  agencies  and  move- 
ments have  necessarily  been  omitted,  such  as  the  abolition 
of  the  common  drinking  cup  in  public  places  in  so  many 
states;13  but  we  must  confess,  that,  after  looking  most  of/ 
them  over  in  the  light  of  the  magnitude,  complexity,  and 
national  character  of  our  health  problem,  the  present 
agencies  seem  rather  purile  and  seriously  inadequate.  We 
are  still  quite  largely  in  the  volunteer,  private  stage  of  health 
provision  evolution. 

A  great  many  good  movements  have  been  started  in 
many  parts  of  the  country;  several  states  and  cities  seem 
to  be  fairly  conscious  of  how  much  of  an  effort  should  be 
made  to  stamp  out  their  preventable  deaths  and  lowered 


MEETING   THE    HEALTH    PROBLEM       65 

vital  efficiency  in  school  and  out;  the  National  Government 
seems  near  to  the  provision  of  a  national  health  bureau  or 
department;  but  on  the  whole  the  few  fairly  adequate 
state  health  laws,  the  few  strong  city  or  state  health  depart- 
ments, the  few  school  systems  to  which  we  can  point  that 
seem  to  comprehend  the  seriousness  of  the  school  health 
problem  and  are  meeting  it  adequately;  all  these  simply 
show  us  that  we  have  but  started  on  the  road  toward  school 
and  national  health  and  normal  physical  development.  It 
is  a  pleasure  and  inspiration  to  live  in  an  age  of  such  change 
and  transition  towiard  better  things. 

The  speed  and  accuracy  with  which  we  adjust  ourselves 
to  our  health  needs  will  undoubtedly  depend  very  much  upon 
how  well  we  study  our  health  problem,  determining  just 
where  it  lies  in  personal,  community,  state,  or  national  con- 
ditions; how  adequately  we  plan  to  meet  the  need;  and  how 
scientifically  we  test  the  effect  our  newly  devised  instruments 
have  upon  the  conditions  we  started  to  ameliorate. 

We  shall  not  proceed  far  in  our  health  provisions  until, 
as  Davenport  and  others  have  shown,  wev  shall  find  that  a 
great  deal  of  our  ill-health  and  physical  defects  are  heredi- 
tary and  that  much  is  brought  out  or  created  by  bad  socio- 
logical conditions.  The  evolutionist,  Wallace,  asserts  that 
our  social  system  is  urotten  from  top  to  bottom,"  that  it 
produces  most  of  the  evils  which  eugenists  would  alleviate, 
and  that  eugenic  reform  must  wait  on  social  reform.  It 
will  be  the  part  of  wisdom,  I  think,  to  combine  both 
methods  of  conscious  social  evolution,  hereditary  and  en- 
vironmental. 

While  the  general  administrative  and  special  technical 

phases  of  health  provisions  in  communities  and  schools  are 

frequently  difficult  and  complex,  yet  the  ends  to  be  reached 

/    are  not  many,   and  comparatively  few  hygienic  principles 

/    are  involved. 

"When  people  have  pure  food,  pure  water,  pure  air, 
and  are  freed  from  the  dust  of  houses,  streets,  and  manu- 
facturing industries;  when  they  have  good  light  and  abund- 
ant sunshine,  sanitary  houses,  barns,  and  outbuildings;  when 


66      SCHOOL  HEALTH  ADMINISTRATION 

they  are  protected  from  germ-carrying  agencies,  such  as  flies, 
mosquitoes,  rats,  mice,  and  all  such  pests;  when  they  are 
protected  from  people  who  are  carriers  of  disease  germs, 
and  taught  how  to  disinfect  their  homes  and  communities; 
when  they  are  taught  to  work  and  play,  eat  and  sleep,  dress 
and  bathe,  according  to  the  laws  of  health;  when  they  learn 
to  care  for  their  teeth  and  their  eyes,  the  main  problems 
of  hygienic  living  will  be  solved  and  human  life  relieved 
of  its  greatest  sources  of  suffering  and  disease." 
— Fletcher  B.  Dresslar,  Ph.D.,  Specialist  in  School  Hygiene 
for  the  United  States  Bureau  of  Education,  in  his  in- 
troduction to  bulletin  528,  on  The  Fifteenth  Interna- 
tional Congress  on  Hygiene  and  Demography. 

REFERENCES 

i.  R.  C.  Newton,  M.D.,  The  Renaissance  of  the  Physical  Conscience 
Popular  Science  Monthly,  1909. 

2.  Ditman,   Education  in  Preventive   Medicine,   Columbia   University 

Publications. 

3.  See  1913  articles  in  Scribner's  Magazine,  and  many  other  publica- 

tions. 

4.  Robert  Bruere's  article  in  the  March,   1912  number  of  Harper's 

Magazine. 

5.  Ditman,  above  referred  to. 

6.  Quoted  by  Elkington,  in  his  "Health  in  the  School." 

7.  Generally  to  be  found  listed  in  the  Survey  Magazine. 

8.  Metropolitan,  and  a  few  others.     Bulletins   are  furnished  persons 

requesting  them. 

9.  Books  by  Stevens,   Kelynack,  Wood,   Crowell,   Hogarth,  Dresslar, 

Burks,  Gulick  and  Ayres  and  the  magazines  such  as  The  Child, 
and   the   Pedagogical  Seminary. 

10.  Ayres,  What  American  Cities  are  Doing  for  the  Health  of  School 

Children,  bulletin  of  the  Sage  Foundation,  division  of  Child  Hy- 
giene. 

11.  Ayres,  Medical  Inspection  Legislation,  bulletin  from  above  Founda- 

tion. 

12.  The  Playground  Magazine,  January,  1912,  and  later  numbers. 

13.  Dresslar,   "School   Hygiene,"   Macmillan. 
Burks'  "Health  and  the  School,"  Appleton's. 

Davenport,  "Heredity  in  Relation  to  Eugenics,"  Holt  &  Co. 
Wallace,  "Social  Environment  and  Moral  Progress." 

OTHER  REFERENCES  USED 

A.  Articles  in  English,  French  and  German  in  the  Transactions  of  the 
Second  International  Congress  on  School  Hygiene. 


MEETING   THE    HEALTH    PROBLEM       67 

B.  The  Annual   Reports  of  the  Chief  Medical   Officer  of  the  Board 

of  Education  of  England,  London,  England,    1909-1912. 

C.  The  recent  volumes  of  the  National   Education  Association  which 

is  devoting  much  attention  to  health  matters  and  has  even  changed 
the  name  of  one  division  from  that  of  Child  Study  to  that  of 
Child  Hygiene.  The  1912  Report  has  about  30  articles,  reports, 
etc.  (173  pp.)  devoted  to  various  aspects  of  Educational  Hygiene, 
a  change  from  little  above  zero  before  1900. 

D.  Many  of  the  flood  of  articles,  reports,  investigations,  etc.,  appear- 

ing in  current  books  and  periodicals,  entirely  too  numerous  to 
mention. 

E.  The   very   valuable   and   suggestive    account   of   "Typical    Health- 

Teaching  Agencies  of  the  United  States,"  Chapter  12,  Vol.  I,  of 
the  1912  Report  of  the  Commissioner  of  Education,  by  Dr. 
F.  B.  Dresslar,  Specialist  "in  School  Hygiene. 

F.  Reports  of  the  National  School  Hygiene  Association. 


COMPULSORY  EDUCATION  AND 
CONTAGIOUS  HEALTH 

"The  human  race  will  be  a  better  race  because 
of  the  lessons  that  have  been  taught  us  by  the 
child  having  contagious  disease,  the  backward 
child,  and  the  physically  defective  child.  Be- 
'  cause  of  these  lessons,  the  youth  of  the  future 
will  attend  a  school  in  which  health  will  be  con- 
tagious instead  of  disease,  in  which  the  play- 
ground will  be  as  important  as  the  book}  and 
where  pure  water,  pure  air,  and  abundant  sun- 
shine will  be  rights,  and  not  privileges.  He 
will  attend  a  school  in  which  he  will  not  have 
to  be  truant,  tuberculous,  delinquent,  or  defec- 
tive, to  get  the  best  and  fullest  measure  of  edu- 
cation."— Gulick  and  Ayres,  in  "Medical  Inspec- 
tion of  Schools." 


PART  TWO 

HOW  THE  PROBLEM  OF  EDUCATIONAL  HYGIENE  IS 
BEING  MET  IN  TWENTY-FIVE  CITIES 


TEACHERS  OF  THE  WHOLE  CHILD 

"The  teacher  should  be  held  to  more  rigid  re- 
quirements in  regard  to  hygiene.  Every  teacher 
should  be  something  of  a  physician.  Our  indif- 
ference to  the  physical  phase  of  education  is  sug- 
gested by  the  fact  that  today  a  teacher  may  have 
passed  from  the  kindergarten  and  through  the 
university  and  still  not  know  how  to  prevent  or 
cure  a  cold.  Not  to  know  something  about  the 
preservation  of  health,  to  say  nothing  of  the 
detection  of  physical  defects  such  as  adenoids, 
enlarged  tonsils,  bad  eyes,  faulty  heart,  weak 
lungs,  etc.,  is,  on  the  part  of  the  teacher,  inex- 
cusable ignorance.  A  doctor  of  philosophy  with 
a  cold  in  the  head  suggests  a  humorous  interpre- 
tation of  the  old  doctrine  that  nature  abhors  a 
vacuum." — Howerth,  in  Education  for  May, 
1907. 


CHAPTER    IV 
GENERAL   PHASES  OF   HEALTH   ADMINISTRATION 

A.   The  Investigation. 

I.    THE   PROBLEM 

BECAUSE  of  the  tremendous  sociological  importance  of 
the  schools'  health  functions ;  because  so  little,  comparatively, 
is  known  about  what  the  schools  are  actually  doing  for 
health  in  a  detailed  way;  and  because  cities,  getting  the 
social  contagion  of  the  health  movement,  are  hastily  copy- 
ing the  work  of  other  localities  without  definite  standards 
for  the  newer  health  provisions  in  the  schools,  it  was  con- 
sidered desirable  that  personal  visits  be  made  to  a  large 
number  of  typical  cities,  and  studies  made  of  their  admin- 
istration of  educational  hygiene,  and  especially  of  medical 
inspection.  The  problem  is  too  vast  for  any  complete 
description  or  evaluation  of  health  provisions  by  one  person 
in  two  or  three  years.  Adequately  to  determine  the  health 
needs,  and  to  describe  and  evaluate  the  work  of  educational 
hygiene  in  one  city  is  an  enormous,  but  much  needed,  task. 
Consequently,  only  the  larger  phases  can  be  dealt  with,  and 
only  one  phase,  medical  inspection,  can  be  dealt  with  in 
any  detail. 

Some  of  the  problems  with  which  the  investigation 
began  are  as  follows : 

1.  How  much  does  it  cost? 

2.  What    are    the    types     of     administration     and     their     relative 
efficiency  ? 

3.  Is   there   better   scientific   management   of   medical   supervision 
by  Boards  of  Health  or  by  Boards  of  Education? 

4.  What  effect  has  such  work  on  the  health  of  the  children? 

5.  What  effect  has  it  upon  pupil-efficiency  in  the  schools? 

6.  What  is  the  relative  merit  of  school  nurses  and  doctors? 

71 


72      SCHOOL  HEALTH  ADMINISTRATION 

7.  What  are  found  to  be  the  principal  ailments  of  school  children, 
how  may  they  be  classified,  and  what  is  their  relative  frequency? 

8.  What  is  the   attitude  of  the  public  and  the  physicians  to  the 
enlargement  of  such  work? 

9.  Of  all  the  ailments  and  defects  found  how  many  are  actually 
treated   and  cured  ? 

10.  How  great  is  the  need  for  free  treatment,   and  how  are  the 
cities  responding? 

11.  How  much  preventive  work  is  being  done  by  the  cities  in  the 
way  of  play  and  playgrounds,  open  air  schools,  better  school  ventilation, 
physical  training,  education  of  parents  along  health  lines,  school  baths 
and  swimming  pools,  investigations  into  the  health  condition  of  school 
children,  and  the  like? 

These  and  many  other  questions,  gradually  reshaping 
themselves  as  the  investigations  went  on,  were  prominent. 
Only  a  few  can  be  satisfactorily  answered.  Our  ignorance 
of  school  health  is  vast  and  profound.  Educators  have  been 
engrossed  largely  with  other  matters.  A  partial  list  of  the 
great  host  of  unsolved  problems  in  this  field  has  been  well 
set  forth  by  Professor  Lewis  M.  Terman  in  the  March 
(1912)  Popular  Science  Monthly.  It  is  significant  that  there 
are  but  two  or  three  chairs  of  educational  hygiene  in  the 
universities  of  this  country. 

2.    THE   DATA  AND  THE   METHOD 

Those  cities  were  selected  for  investigation  which  had 
both  school  doctors  and  nurses  and  were  in  the  eastern 
part  of  the  United  States.  They  were  located  from  the 
Russell  Sage  Foundation  investigation  previously  men- 
tioned. There  were  about  forty-five  such  cities  that  had  both 
school  doctors  and  nurses  at  or  near  the  beginning  of  the 
school  year  1910-11.  After  visiting  most  of  these  and 
several  others  (forty  in  all)  fifteen  were  finally  eliminated 
for  one  reason  or  another,  New  York  City,  Baltimore  and 
Philadelphia  because  they  were  too  vast  to  be  typical;  others 
because  too  little  definite  data  could  be  discovered;  others 
because  the  work  had  begun  too  late  in  the  school  year; 
and  still  others  because  either  the  nurse  or  physician  was 
employed  by  private  organizations;  or  the  work  had  just 
changed  over  from  the  Board  of  Health  into  the  hands  of 
the  Board  of  Education  (e.  g.,  Ithaca,  N.  Y.). 


THE   TWENTY-FIVE    CITIES  73 

At  least  one  visit,  a  half  day  to  a  week  in  length,  was 
made  to  each  city,  and  as  many  as  ten  visits  were  made 
to  certain  nearby  cities.  The  time  of  visiting  was  in  the 
school  years  of  1910-11  and  1911-12  and  the  intervening 
summer  when  playground  and  other  such  work  could  be 
seen.  Additional  visits  have  been  made  in  the  school  year 
of  1912-13.  A  weak  point  of  the  investigation  was  the 
inadequate  time  for  many  cities,  and  the  frequent  inability 
to  see  the  various  health  agencies  in  actual  operation. 
Where  medical  inspection  was  administered  by  the  Boards 
of  Health  these  agencies  were  studied  as  well  as  the  schools, 
and  where  several  agencies  carried  on  the  work  all  were 
studied.  Board  of  Health  reports  from  all  the  cities  have 
been  used  as  well  as  the  United  States  Mortality  Statistics 
for  1910  and  the  reports  of  the  United  States  Bureau  of 
Education.  It  has  been  found  necessary,  also,  to  study  the 
work  of  cities  having  only  school  doctors,  or  only  school 
nurses  for  comparison  with  the  group  selected.  The  experi- 
ences of  European  and  other  countries  have  also  been  drawn 
upon.  The  attempt  throughout  has  been  to  fit  the  investiga- 
tion to  the  actual  conditions  found,  not  the  facts  to  a  pre- 
arranged theory  or  questionnaire.  The  heterogeneity  of 
the  findings  by  such  a  method,  for  work  so  new  and  tenta- 
tive, beggars  description. 

Late  in  the  study  the  writer  had  the  good  fortune  to  be 
employed  by  the  Board  of  Education  of  one  of  the  twenty- 
five  selected  cities,  probably  nearest  of  all  to  the  city  of 
typical  size  in  this  country,  to  investigate  the  work  of  the 
so-called  medical  inspection  and  to  report  a  tentative, 
standardized  plan  for  reorganization  and  growth.  Full 
powers  were  given  in  the  way  of  calling  for  the  judgments  of 
teachers,  principals,  physical  trainers,  physicians  and  nurses; 
and  for  looking  into  the  work.  Though  the  time  available 
was  entirely  too  short,  a  good  deal  of  fresh  light  was  thus 
thrown  on  the  general  problem. 

We  shall  first  take  up  the  work  of  medical  inspection 
with  its  display  of  pathological  conditions  and  consequent 
health  needs,  in  the  schools  and  homes.  Later,  brief  descrip- 


74      SCHOOL  HEALTH  ADMINISTRATION 

tions  and  evaluations  of  other  phases  of  educational  hygiene 
of  a  preventive  and  development  nature  will  be  offered. 

3.     MEDICAL     INSPECTION     OF     SCHOOLS     IN    TWENTY-FIVE 

CITIES 

The  following  tables  attempt  to  display  in  convenient 
form  some  of  the  main  facts  about  the  work  of  medical 
inspection  in  the  twenty-five  cities.  Some  general  facts 
relating  to  the  city  and  the  schools,  necessary  for  compre- 
hension of  the  situation  and  for  later  efficiency  tests,  are 
given  first.  Many  facts  refuse  to  enter  the  squares  of  a 
statistical  table,  and  foot-notes,  description  and  qualifica- 
tions are  necessary.  Even  then  the  data  are  relatively 
inaccurate,  for  many  reasons,  but  chiefly  because  of  the  lack 
of  efficient  records  in  practically  all  cities.  When,  for 
example,  a  medical  inspector  has  been  discharged  for  sending 
in  reports  based  on  nothing  more  than  entering  the  lower 
hall  of  a  school  and  signing  his  name  in  a  book,  some  doubt 
is  cast  over  his  and  perhaps  others'  statistics  in  that  city. 
Further,  most  of  the  blank  forms  for  recording  the  work 
are,  as  yet,  so  poorly  devised  that  it  is  almost  impossible  to 
record  or  summarize  work  done,  or  correlate  it  with  results 
accomplished.  The  poor  clerks,  devoid  of  medical  knowl- 
edge, who  have  to  make  up  a  majority  of  the  summaries 
from  such  data  help  to  make  even  more  inaccurate  the 
results.  Some  cities  have  met  the  situation  by  making  no 
annual  reports  or  very  meager  and  inadequate  summaries. 
To  get  back  of  this  difficulty  it  was  necessary  to  spend 
several  months  in  summarizing  the  daily,  weekly  or 
monthly  reports  of  doctors  and  nurses  in  a  number  of  cities. 
The  knowledge  gained  from  such  work  was,  however,  well 
worth  the  tedious  labor.  The  large  number  of  cases  proba- 
bly helps  some  to  cover  up  many  inaccuracies,  and  the  gen- 
eral facts  here  selected  and  presented  are  probably  as  accu- 
rate as  can  now  be  obtained.  Our  hope  is  that  the  study 
will  lead  to  greater  efficiency  in  this  field. 


THE  TWENTY-FIVE  CITIES  75 

B.    Correlations  With  Population  of  the  Cities. 

From  these  statistics  it  can  be  seen  that  the  cities  and 
towns  studied  are  scattered  over  five  states  and  range  in 
size  from  7,500  population  to  670,583,  1910  census.  Within 
this  range  are  included  most  of  the  municipalities  of  the 
country  so  the  data  of  our  study  can  be  regarded  as  fairly 
typical  in  this  respect.  Since  the  cities  are  arranged  in 
order  of  size  (Columns  i,  2,  3),  questions  immediately 
arise  as  to  the  correlation  of  this  increase  with  the  admin- 
istrative provisions.  In  the  next  column  (4)  it  can  be  seen 
that  as  the  cities  increase  in  size  more  and  more  of  them 
have  medical  inspection  administered  by  Boards  of  Health. 
This  may  be  due  to  chance,  but  is  more  probably  due  to  the 
fact  that  when  medical  inspection  began  a  few  years  ago  it 
was  confined  for  the  most  part  to  the  larger  cities,  and  was 
under  the  Boards  of  Health.  The  1906  Massachusetts 
law  prevents  cities  from  taking  the  work,  where  already 
begun,  out  of  the  hands  of  the  Boards  of  Health  and  put- 
ting it  into  the  hands  of  the  Boards  of  Education.  The 
smaller  cities,  as  shown  by  the  column  giving  the  dates  when 
medical  inspection  was  begun,  have  started  the  work  for 
the  most  part  since  the  change  of  public  opinion  and  state 
laws  have  placed  the  work  in  the  hands  of  the  Boards  of 
Education.  In  New  Bedford  and  Boston  the  work  is  di- 
vided, the  Boards  of  Health  having  the  school  doctors  and 
the  Boards  of  Education  the  nurses. 

I.    SALARIES  AND  SIZE  OF  CITY 

Only  the  larger  cities  have  special  supervisors  of  medi- 
cal inspection,  Syracuse  under  the  Board  of  Health,  Jersey 
City  and  Newark  under  the  Boards  of  Education,  and  Bos- 
ton with  a  supervisor  employed  by  each  board.*  No  signifi- 
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salary  paid  either  to  physicians  or  nurses.  Some  small 
cities  pay  little  and  some  much;  the  same  is  true  of  the 
larger  ones.  The  supervisors'  salaries  tend  to  increase  with 

*The  Board  of  Education  in  Boston  has  both  a  general  Director 
of  Hygiene  and  a  Supervisor  of  Nurses. 


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78        SCHOOL  HEALTH  ADMINISTRAION 

the  size  of  the  city,  indicating,  perhaps,  a  recognition  of  the 
possibilities  of  more  responsibility  if  not  more  work  in  the 
larger  places  (Columns  19  and  20). 

2.  NUMBER  OF  DOCTORS  AND  NURSES 
When  we  come  to  the  number  of  doctors  and  nurses 
(Columns  19  and  20),  a  surprisingly  low  correlation  is 
found.  The  numbers  by  no  means  increase  proportionately 
with  the  size  of  the  city  or  the  number  of  pupils  in  the 
school  systems.  If  the  first  five  cities  require  the  entire 
time  of  one  nurse  each,  then,  taking  1,735,  their  average 
enrollment  as  a  trial  standard,  Boston  should  have  about 
63  nurses  instead  of  34  and  Newark  45  instead  of  eight. 
Providence  would  have  20  instead  of  one.  It  is  evident 
from  these  figures  that  there  are  as  yet  no  very  definite 
standards  established  or  attained  in  this  field.  The  writer 
found  the  nurse's  time  well  occupied  in  these  smaller  cities. 
Since  the  problem  increases  somewhat  with  the  size  and 
congestion  of  the  city  it  would  seem  reasonable  from  this 
correlation  that  while  the  smaller  cities  may  be  fairly  well 
supplied  with  nurses,  the  larger  cities  have  a  woeful  insuffi- 
ciency. However,  the  number  of  physicians,  the  size  of  the 
schools  and  the  distances  between  them  are  all  factors. 

There  is  a  closer  correlation  between  the  number  of 
physicians  and  the  size  of  the  city,  than  for  the  nurses. 
Physicians  were  the  first  to  be  appointed  and  the  cities  have 
been  districted  largely  on  the  basis  of  physicians,  not  nurses. 
Taking  the  same  average  enrollment  for  the  first  five  cities 
(I?735)  we  find  tnat  if  these  small  cities  each  need  one 
physician  two  hours  a  day,  Boston  should  have,  on  this  basis, 
(counting  each  supervisor  as  two  physicians),  63  physi- 
cians instead  of  82,  Newark  45  instead  of  39,  and  Provi- 
dence 20  instead  of  four.  It  can  be  seen  that  most  cities  have 
fewer  physicians  than  this  trial  standard  calls  for. 

PHYSICIAN-NURSE    UNIT 

But  the  number  of  physicians  employed  depends  largely 
upon  the  number  of  nurses  in  the  system  and,  vice  versa,  it 
may  be  said;  so  the  unit  standard  should  really  be  the 


THE  TWENTY-FIVE  CITIES  79 

physician-wY/z-the-nurse,  the  physician-nurse  unit.  Applying 
again  the  average-pupil-enrollment  standard,  Boston  would 
have  63  doctors  and  63  nurses,  and  the  other  cities 
proportionate  numbers.  The  combined  number  for  Boston 
would  be  126  instead  of  the  present  120,  (80+2)  + 
(34+2+2),  a  very  small  difference.  (Column  47).  For 
Newark  the  combined  number  would  be  90  instead  of  47, 
(37+8+2)  ;  and  for  Providence  40  instead  of  five.  The 
combined  number  based  on  this  standard  is  given  in  con- 
trast to  the  actual  combined  numbers  for  each  city  in 
columns  46  and  47.  The  ratio  of  the  actual  combined 
number  to  the  standard  number  is  given  in  column  48. 
Glancing  down  this  column  (48)  we  note  an  increasing 
falling  away  from  the  tentative  trial  standard  number  of 
physicians  and  nurses  until  we  reach  the  last  city,  Boston, 
(95.47),  where  a  surprisingly  close  correspondence  is 
reached.  The  only  city  having  more  than  the  standard 
number  is  Montclair  and  its  superiority  is  apparent  rather 
than  real,  for  its  physicians  visited  the  schools  only  twice 
a  week  instead  of  five  times,  and  spent,  on  the  average, 
only  about  one  hour's  time  to  a  visit. 

THE  PHYSICIAN HOURS  A  WEEK NURSE  STANDARD 

This  shows  the  necessity  for  a  trial  standard  which  will 
include  the  number  of  hours  a  week  the  physicians  actually 
spend  in  the  school  work.  Later  a  general  working  stand- 
ard will  be  developed  which  will  include  the  number  of 
daily  visits  a  year,  and  other  matters,  but  for  the  quick 
comparison  of  cities  the  following  plan  may  be  used:  Count 
as  a  physician-working-unit  one  who  gives  five  hours  a 
week  (an  hour  a  day)  to  the  schools.  Rules  and  regula- 
tions are  extremely  chaotic;  and  it  is  difficult  in^the  hetero- 
geneity to  learn  exactly  how  many  hours  physicians  actually 
do  put  in,  on  the  average  (See  columns  30-32)  ;  still  column 
49  will  show  approximately  on  this  comparable  basis  the 
relative  standing  of  the  cities  as  to  numbers  of  doctors  and 
nurses.  At  Montclair,  for  example,  the  five  physicians 
putting  in  two  hours  a  week  are  roughly  equivalent  to  two 
physicians  giving  five  hours  a  week.  Adding  the  nurse 


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82      SCHOOL  HEALTH  ADMINISTRATION 

(Column  49)  to  the  physicians  we  have  the  equivalent 
(other  things  equal)  of  a  working  staff  of  three  instead  of 
six.  While  it  will  be  shown  later  that  probably  two  hours 
a  day,  five  days  a  week  is  a  more  ideal  arrangement,  "stand- 
ard" here  means  only  a  trial  unit  of  measurement  for  put- 
ting variant  facts  on  a  comparable  basis.  Fractions  should 
be  considered  as  parts  of  working-units,  not  of  physicians, 
of  course. 

Leaving  off  the  decimals,  we  see  what  a  variety  of  things 
the  statement  that  a  city  "has  medical  inspection  of  schools" 
may  mean.  (Column  50).  Meriden  stands  at  100  per 
cent;  while  Yonkers  stands  at  1 1  per  cent.  Ten  times  as 
many  hours  of  medical  service  were  given  in  the  former 
city  (not  counting  the  number  of  hours,  nor  daily  visits  a 
year) ,  and  to  one-third  the  number  of  elementary  pupils. 
Taking  the  average  of  the  first  five  cities  again  as  a  basis 
of  comparison  (2,  a  physician  with  a  nurse  each),  and 
J735  as  tne  average  enrollment,  we  can  see  how  many 
physicians  and  nurses  the  cities  would  have  were  they  to 
keep  up  to  the  trial  standard  set  by  the  first  five.  Boston 
again  practically  maintains  the  custom  of  the  small  towns. 
Other  cities  coming  near  to  it,  after  the  five  used  as  a 
standard,  are :  Meriden  and  Newark.  Counting  office 
assistance  in  Boston  and  Newark  there  would  be  almost  the 
same  proportionate  amount  of  medical  inspection  units  as 
in  the  smaller  cities.  In  other  words,  the  two  largest  cities 
almost  keep  up  the  standard  set  by  the  smallest  towns  while 
other  cities  fall  considerably  below. 

The  percentage  figures  in  the  next  column  (50)  show 
how  nearly  the  different  cities  come  to  the  working  stand- 
ard. When  we  see  such  large  and  relatively  efficient  cities 
as  Newark  (95  per  cent),  and  Boston  (95  per  cent), 
practically  coming  up  to  the  standard  set  by  the  smallest, 
and  then  see  Meriden  starting  out  (October,  1910)  on  an 
ably  constructed  plan  of  administration  of  this  work  and 
practically  taking  up  this  standard,  it  appears  that  the 
working  standard  used  here  must  not  be  far  from  what 
actually  seems  necessary.  Its  limitations  will  be  shown 


THE    TWENTY-FIVE    CITIES  83 

later.  In  Summit,  for  example,  with  a  first-class  suburban 
population  the  medical  inspector  really  has  to  put  in  more 
than  an  hour  a  day  five  days  in  the  week,  and,  to  get  the 
work  well  done,  should  be  employed  for  two  hours  in 
actual  medical  work  daily;  but  in  the  year  studied  he  made 
only  125  daily  visits  in  the  school  year  of  188  days. 

Interpreted,  some  of  the  cases  in  this  column  mean,  for 
example,  in  Rochester  and  Jersey  City,*  that  these  cities 
have  about  half  (50%)  as  many  inspectors  and  nurses  as 
would  meet  the  standard  of  the  largest  and  smallest  towns; 
Yonkers  has  about  1 1  %  as  many,  being  most  poorly  sup- 
plied of  all  the  cities.  These  figures,  then,  show  the  approx- 
imate relative  standing  of  the  cities  as  to  the  amount  of 
medical  inspection  forces  per  unit  of  school  enrollment  not 
counting  the  relative  number  of  weeks  employed  in  a  school 
year.  This  does  not  state  what  should  be,  but  what  was. 
The  number  of  nurses  put  into  a  school  system  would  influ- 
ence the  number  of  physicians  needed.  It  is  probable  that 
there  should  be  at  least  an  equal  number,  and  perhaps  more. 
No  data  are  here  given  on  this  problem. 

3.  BOARDS  OF  EDUCATION  VS.  BOARDS  OF  HEALTH 

Is  there  any  light  thrown  by  these  comparative  figures 
on  the  relative  efficiency  of  Boards  of  Health  and  Boards 
of  Education?  If  Boards  of  Health  are  more  responsive 
generally  to  the  needs  of  the  schools  with  respect  to  patho- 
logical health  conditions  than  are  Boards  of  Education 
then  we  should  expect  these  figures  to  show  them  better 
manned  for  the  work  of  medical  inspection,  especially  since 
they  are,  on  the  average,  nearly  three  times  as  old.  What 
are  the  facts?  Leaving  out  the  two  cities,  New  Bedford 
and  Boston,  where  the  responsibility  of  caring  for  the 
health  of  the  school  children  is  divided  between  the  two 

*This  was  the  first  complete  year  of  medical  "inspection"  for  Jersey 
City  and  the  plan  was  not  completely  carried  out.  The  rules  require 
two  hours  a  day,  five  days  a  week,  for  each  physician.  Were  the  actual 
average  ten  hours  a  week,  the  combined  number  would  be  I2X2-J-4-J-6. 
The  twelve  M.  D.'s  would  be  equivalent  to  twenty-four,  the  supervisor 
to  four,  and  the  nurses  to  six;  in  all,  thirty-four,  instead  of  twenty. 


84      SCHOOL  HEALTH  ADMINISTRATION 

boards,  we  can  take  the  average  standing  of  those  cities 
where  this  work  is  administered  by  Boards  of  Education 
and  compare  it  with  the  average  of  the  cities  under  Boards 
of  Health  (Column  50).  The  average  for  the  fourteen 
cities  administered  by  Boards  of  Education  is  76% 
(omitting  Brockton,*  81%)  while  the  average  for  the 
nine  cities  where  the  work  is  in  the  hands  of  the  Boards  of 
Health  is  a  little  over  45%.  This  would  seem  to  indicate 
that  Boards  of  Health  are  not  as  responsive,  or  not  as 
successful,  in  getting  an  adequate  force  of  medical  inspectors 
and  nurses  as  are  Boards  of  Education.  Even  leaving  off 
the  first  five  cities  and  comparing  the  nine  remaining  cities 
with  the  nine  others,  the  Boards  of  Education  stand  at 
about  62%  while  the  Boards  of  Health  stand  at  about 

45%- 

An  alternative,  however,  remains:  That  the  Boards  of 
Health  may  be  able  to  use  more  efficiently  a  given  number 
of  medical  inspectors  and  nurses  than  could  the  Boards  of 
Education.  This  remains  for  later  solution  when  the 
amounts  and  quality  of  work  done  are  compared.  It  may 
be  said  here,  however,  that  in  general  they  seem  to  use 
them  far  less  efficiently  than  do  Boards  of  Education. 

Under  Boards  of  Education.  Under  Boards  of  Health. 

Montclair    75  Mt.  Vernon   83 

Meriden    100  Newton    87 

Brockton*     20  Schenectady    20 

Hoboken    58  Waterbury    28 

Yonkers    II  Cambridge    35 

Trenton    83  New  Haven   28 

Lowell    71  Syracuse     64 

Jersey  City 50  Rochester    50 

Newark    95  Providence     12 

563  407 

Average,  62%,  without  Brockton,  67%.  Average,  45%. 

4.    TENDENCIES  IN  MEDICAL  SUPERVISION 

Without  carrying  any  further  the  correlations  between 

*Brockton  is  exceptional  for  the  reason  that  it  is  practically  elim- 
inating physicians,  using  them  for  consultation  by  the  nurse  only.  This 
marks  the  begininng  of  a  growing  tendency. 


THE   TWENTY-FIVE    CITIES  85 

the  increase  in  size  of  the  cities  and  their  school  populations, 
we  can  see  something  of  the  tremendous  heterogeneity  and 
relative  status  of  cities  in  this  work.  Another  preliminary 
problem  arises  as  to  the  tendencies  shown  by  these  25  cities. 
How  rapidly  is  medical  supervision  coming  into  our  cities, 
and  is  its  administration  going  into  the  hands  of  the  Boards 
of  Education  or  the  Boards  of  Health?  The  facts  are 
shown  by  the  following  table  ( Column  5 )  : 

Two  began  Medical  Supervision  in  1894,  both  by  Board 
of  Health.  One  now  partly  Board  of  Education. 

Two  began  Medical  Supervision  in  1901,  one  Health 
and  one  Education,  formerly  Health. 

One  began  Medical  Supervision  in  1903,  Education. 

One  began  Medical  Supervision  in  1904,  Health. 

Four  began  Medical  Supervision  in  1905,  two  Health 
and  two  Education. 

Four  began  Medical  Supervision  in  1906,  three  Health 
(one  partly  Education)  and  one  Education. 

Two  began  Medical  Supervision  in  1907,  both  Health, 
one  partly  Education. 

Three  began  Medical  Supervision  in  1908,  all  Educa- 
tion. 

Three  began  Medical  Supervision  in  1909,  all  Educa- 
tion. 

Three  began  Medical  Supervision  in  1910,  all  Educa- 
tion. 

None  of  the  nine  cities  starting  since  1907  has 
intrusted  this  work  to  Boards  of  Health.  The  work  began 
with  the  Boards  of  Health  but  it  is  now  being  placed  in 
the  hands  of  the  Boards  of  Education.  In  New  Jersey  the 
1909  law  placed  all  the  systems  then  existing  under  the 
Board  of  Education,  four  of  these  cities. 

This  table  for  these  twenty-five  cities  corresponds  closely 
to  the  one  made  for  1,038  cities  given  earlier.  It  shows 
a  very  remarkable  acceleration  since  1904-5,  an  increase 
so  rapid  as  to  point  to  the  movement  spreading  soon  to  all 
cities.  In  these  cities,  too,  the  nurses  have  all  been  added 
since  1906  when  Boston  started  the  movement  on  a  large 


86      SCHOOL  HEALTH  ADMINISTRATION 

scale,  practically  all  having  been  added,  indeed,  since  1908. 
(Column  6).  A  tendency,  not  yet  to  be  shown  in  figures, 
exists  toward  increasing  the  number  of  nurses  and  decreas- 
ing the  number  of  physicians.  One  city,  Brockton,  dropped 
three  of  its  physicians  (keeping  two  paid  and  one  volun- 
tary physician  for  consultation  only) ,  and  put  one  nurse  in 
their  place.  This  was  at  the  instance  of  physicians  them- 
selves, one  of  whom  is  on  the  Board  of  Education. 

Newark  is  now  changing  to  almost  the  same  plan,  using 
a  few  physicians  as  district  medical  supervisors  of  a  large 
number  of  nurses.  Oakland,  Cal.,  and  Albany,  N.  Y.,  have 
the  same  general  plan. 

C.   WHAT  DOES  MEDICAL  SUPERVISION   COST? 

a.  Salaries  of  Supervisors  and  Office  Help 

The  salaries  of  physicians  range  from  $200  to  $1,200 
as  regular  examiners  or  inspectors.  One,  a  member  of  a 
Board  of  Education,  gives  his  services  free  of  charge  (at 
Brockton).  The  salaries  of  the  head-physicians,  or  super- 
visors, range  from  $800  to  $3,780,  as  follows: 

Syracuse,  $800. 

Jersey  City,  $1,500. 

Newark,  $1,800. 

Boston:  Board  of  Health,  $2,500;  Board  of  Educa- 
tion— General  Supervisor  Department  of  Hygiene,  $3,780; 
Supervisor  of  Nurses,  $1,500. 

None  of  these  supervisors  gave  full  time  to  the  work, 
excepting  the  woman  who  is  supervisor  of  nurses  in  Boston. 
From  three  to  four  hours  a  day  was  expected  or  given  by  the 
other  supervisors.  These  figures,  of  course,  do  not  give 
credit  to  the  large  amount  of  supervising  time  given  either 
by  the  superintendents  of  schools  or  of  boards  of  health  in 
certain  cases.  They  refer  only  to  those  officials  who  have 
been  definitely  set  apart  for  this  specific  work  alone  and 
who  are  paid  a  salary  for  it.  Each  of  these  supervisors  has 
office  help,  either  the  general  office  force  as  in  boards  of 
health,  or  special  assistants  as  in  the  case  of  the  schools. 
Jersey  City  has  one  stenographer  on  half  time,  and  here 
only  records  of  excluded  children  are  summarized.  In  New- 


THE   TWENTY-FIVE-  CITIES  87 

ark,  the  supervisor  has  a  well  appointed  office  and  two 
efficient  clerks  on  full  time.  Even  these  are  not  able  to 
do  all  the  work  desirable  to  keeping  track  of  37  to  38 
inspectors  and  eight  nurses  with  daily  reports,  a  sani- 
tary inspector  and  large  amounts  of  medical  supplies. 
Analysis  of  results  and  adequate  checking  up  and  reporting 
are  difficult.  In  Boston,  the  school  Supervisor  of  Hygiene 
and  the  Supervisor  of  Nurses  have  but  one  clerk.  To  meet 
this  situation  nurses  are  there  required  to  hand  in  reports 
only  every  three  months.  Of  course,  there  are  no  physicians 
to  look  after  as  they  are  under  the  direction  of  the  Board 
of  Health.  The  efficiency  of  reporting  only  every  three 
months  instead  of  daily  or  weekly  is  very  doubtful. 

b.  Salaries  of  School  Physicians 

The  gross  salaries  of  physicians  seem  very  low.  The 
average  salary  is  $398,  practically  $400  a  year.*  The 
median  salary  is,  however,  only  about  $300,  half  of  the 
cities  having  less  than  this  salary  and  half  having  more, 
while  only  six  pay  more  than  $400.  The  three  cities  which 
pay  $1,000  and  over  are  exceptional.  In  two  of  these,  as 
will  be  shown  later,  the  salary  is  probably  higher  in  pro- 
portion to  services  rendered  than  is  necessary.  Distinctions 
must  continually  be  made  between  the  number  of  hours 
required  by  the  rules  or  expected  by  the  Board  and  the 
number  of  hours  which  are  actually  given  to  the  school 
work.  These  three  cities  require  twice  or  three  times  as 
much  time  a  day  as  is  customary,  two  and  three  hours 
instead  of  one.  Boston  had  80  physicians  at  a  dollar  or 
less  an  hour;  for  some  physicians  put  in  more  than  the 
required  hour  a  day.  This  has  since  been  changed  to  two 
hours  a  day  and  $500  a  year. 

A  salary  of  $300  for  ten  months,  counting  twenty 
school  days  to  a  month,  and  a  visit  of  an  hour  a  day,  five 
days  in  the  week,  means  $30  for  20  hours,  or  $1.50  a  visit, 

*Newark  has  since  changed  from  thirty-seven  physicians  at  $300 
a  year  to  thirty-eight  physicians  at  $400,  giving  strictly  two  hours  to 
the  school  work  each  day  since  many  physicians  have  but  one  school. 
Further  changes  emphasizing  the  nurse  are  now  taking  place,  however. 
See  page  84. 


88      SCHOOL  HEALTH  ADMINISTRATION 

or  hour.  $400  means  $2  an  hour.  These  are  not  far 
from  the  regular  charges  of  average  physicians  in  private 
practice.  The  public  service  is  far  more  regular,  very  few 
patients  indeed  requiring  a  physician's  services  daily  nearly 
1 80  times  a  year.  It,  moreover,  brings  the  physician  into 
touch  with  a  great  number  of  present  and  future  citizens, 
which  will,  in  many  cases,  increase  his  practice.  The  main 
drawbacks  seem  to  be,  first,  that  the  school  hour,  or  hours, 
should  be  given  at  practically  the  same  time  each  day,  thus 
interfering  with  possible  private  practice;  second,  that  the 
work  is  of  such  a  routine  character  that  the  physician  very 
soon  tires  of  it;  and  third,  that  the  conscientious  physician 
is  frequently  disheartened  in  the  attempt  to  do  in  an  hour, 
an  hour-and-a-half,  or  even  two  hours,  all  that  needs  to  be 
done  in  service  to  the  children.  To  emphasize  the  second 
point,  Dr.  Cornell's  frequent  mention  of  the  physical  strain 
of  prolonged  examinations  may  be  quoted  from  his  book 
on  "Health  and  Medical  Inspection  of  School  Children." 
In  speaking  of  vision  testing,  page  42,  he  says:  "Anyone 
who  has  examined  for  two  hours,  alternately  standing  beside 
a  test  card  with  a  pointer  and  going  to  a  table  or  desk  to 
make  the  record,  using  constantly  the  eyes,  voice,  and  body, 
with  the  added  effort  of  instructing  each  child  clearly  what 
to  do  and  how  to  do  it,  will  testify  to  absolute  fatigue  experi- 
enced, as  well  as  the  feeling  of  eye-strain  ensuing."  And 
again  on  page  43,  "An  hour  and  a  half  of  eye  testing  is 
almost  sufficient  to  start  up  a  headache  in  any  examiner, 
no  matter  how  perfect  his  eyesight,  and  phlegmatic  his 
temperament."  These  effects  are  practically  universal  and 
are  mentioned  by  most  of  the  English  writers  on  this  sub- 
ject. It  would  seem  that  the  strictly  medical  examination, 
not  including  vision  or  hearing  tests,  is  just  as  fatiguing  and 
that  those  who  claim  physicians  should  be  employed  for 
the  entire  day  (excepting  the  supervisor  who  could  vary 
his  work)  as  is  the  teacher  or  nurse,  are  wrong;  and  the 
best  scientific  management  would  make  the  physician's 
expert  services  last  little  longer  than  two  hours  daily.  For 
full-time  service  the  problem  becomes  one  of  providing 
other  work  for  each  half  day.  The  nurse,  of  course,  can 


THE    TWENTY-FIVE    CITIES  89 

easily  alternate  her  work  with  home  visiting.  It  is  doubtful 
if  any  first-class  physicians  could  be  found  who  would  de- 
vote their  entire  days  to  medical  examinations  of  pupils. 
All  the  writer  has  questioned  asserted  this  emphatically. 
The  ideal  for  the  physician  at  present  would  seem  to  be 
two  hours  a  day,  taking  no  part  of  the  two  hours  in  going 
from  one  school  to  another.  Inevitably  school  physicians 
will,  however,  be  provided  on  full  time.  The  problem 
has  not  yet  been  solved.  Several  very  large  cities  now 
have  full-time  physicians,  of  course,  but  the  salaries  are 
large,  and  we  are  looking  here  more  to  average  or  typical 
cities. 

These  salaries  as  printed,  however,  do  not  show  com- 
paratively what  the  real  salaries  are.  The  number  of  hours 
a  day,  week,  and  year,  the  quality  and  the  difficulty  of  the 
service  must  all  be  considered.  Leaving  out  the  last  two 
for  the  present,  let  us  see  what  the  salaries  are  in  terms  of 
hours  spent  in  the  school  service.  Columns  32  and  51  give 
respectively  the  number  of  hours  a  week  each  physician 
gives  on  the  average,  as  nearly  as  could  be  determined,  and 
what  each  hour  cost  the  city.  The  second  column  then 
gives  fairly  accurately  the  real  comparative  salaries,  omit- 
ting the  number  of  daily  visits  in  the  school  year,  which 
varies  greatly.  Where  cities  have  no  rules  governing  this 
matter  or  have  physicians  only  "on  call"  estimates  have 
been  made,  with  the  help  of  some  supervising  official,  of  the 
average  number  of  hours  a  week  inspectors  spent  in  the 
schools.  Likewise,  where  the  work  is  new  and  the  adminis- 
trative measures  not  yet  perfected  estimates  have  necessarily 
been  used.  Some  inspectors  will  perhaps  find  that  their 
individual  amount  of  time  is  underestimated  by  these  figures; 
others,  overestimated.  Had  we  facts  for  all  cities  the  num- 
ber of  daily  visits  a  year  should  be  taken  into  consideration 
as  an  important  item.  Wholesale  absence  is  common  in 
some  cities. 

These  salaries  stated  in  terms  of  wages-per-hour 
range  from  $i  to  $6.25.  If  it  could  be  shown  that  the 
physicians  at  Yonkers  gave  an  average  of  more  than  an 
hour  a  day  twice  a  week,  then  this  largest  salary  would  be 


90      SCHOOL  HEALTH  ADMINISTRATION 

decreased,  and  perhaps  some  other  city  would  stand  highest. 
The  facts  are  for  the  year  1910-11.  The  average  wage  per 
hour  for  the  25  cities  is  $2.30  and  the  median  wage  is  $2, 
half  of  the  cities  paying  less  than  this  amount  and  half  pay- 
ing the  same  or  more.  Only  five  cities  pay  more  than  $2.50 
an  hour  and  only  three  pay  as  low  as  one  dollar.  If  the 
four  cities  paying  over  three  dollars  actually  had  a  larger 
average  number  of  hours  service  for  each  physician,  which 
may  be  possible,  the  average  and  the  median  for  all  would 
not  be  far  from  $1.50  an  hour.  The  Newark  change  from 
$1.50  to  $2  a  visit  of  two  hours  each,  five  days  a  week,  is  in- 
teresting in  this  connection.  Of  course,  where  the  calendar, 
instead  of  the  four-weeks  school  month,  is  used,  physicians 
get  a  little  less  an  hour.  It  is  very  doubtful  if  it  is  an  effi- 
cient use  of  public  money  to  pay  more  than  $1.50  an  hour 
(three  dollars  for  a  two-hour  visit).  If  Boston  can  get  80 
physicians  year  after  year,  Newark  38,  and  many  other 
smaller  cities  can  get  good  average  physicians  for  a  dollar 
an  hour,  this  sum,  especially  in  the  two  hour  a  day  plan, 
would  seem  to  be  a  reasonable  minimum.  Sixty  dollars  a 
month  regularly  ($1.50  an  hour)  seems  to  be  average 
physicians'  earnings,  much  better  than  many,  and  better  than 
the  teachers  in  the  schools  obtain.  Where  more  is  paid, 
say  two  dollars  an  hour  or  $800  a  year,  diminishing  returns 
bring  in  the  school  nurse  who  can  be  had  on  full-time 
eleven  instead  of  ten  months  in  the  year,  and  who  is  often 
more  efficient  hour  by  hour  for  the  relatively  simple  work 
of  school  inspection  than  the  physicians. 

c.  Nurses'  Salaries 

The  salaries  of  nurses  are  fairly  well  standardized. 
Nurses  in  a  large  number  of  schools  work  from  8  130  or 
9  :oo  in  the  morning  until  4  :oo  to  6  :oo  in  the  afternoon, 
with  a  half  hour  to  an  hour  off  for  lunch.  Generally  the 
plan  is  to  have  the  nurse  at  the  school  about  fifteen  minutes 
before  school  begins  in  the  morning;  and  to  require  her  to 
do  home  visiting  after  school  until  five-thirty  or  a  little  later. 
Home  visiting  may  also  be  done  in  school  hours  in  many 
places.  On  Saturday,  the  nurse  makes  home  visits  from 


THE    TWENTY-FIVE    CITIES  91 

eight  or  nine  to  twelve  o'clock.  For  these  five-and-half 
days  a  week  with  Saturday  afternoons  frequently  devoted  to 
statistical  records  and  reports,  the  nurses  receive  salaries 
ranging  from  a  little  over  fifty,  to  ninety  dollars  a  month, 
ten,  and,  in  some  cases,  eleven  or  twelve  months  in  the 
year.  Boards  of  health  quite  regularly,  though  with  excep- 
tions, employ  the  nurses  for  twelve  months  with  salaries  of 
eight  or  nine  hundred  dollars  a  year.  In  the  summer  and  at 
other  times  when  not  engaged  in  school  medical  inspection, 
the  Board  of  Health  nurses  do  the  regular  district  and 
other  nursing. 

In  Schenectady  the  nurses  each  spend  a  month  of  the 
summer  in  the  Open  Air  School  with  one  month  vacation 
each.  In  Boston,  the  school  nurses  are  paid  in  twelve 
annual  installments  and  may  be  called  upon  for  service 
during  the  summer  vacation,  but  as  yet  they  have  been 
free.  The  tendency  is  toward  keeping  a  part  or  all  of  the 
nurses  in  relays  during  the  summer  (each  nurse  getting  a 
month's  vacation)  for  the  inspection  of  children  in  vacation 
schools  and  playgrounds  and  for  the  home  visiting  which 
seems  necessary  to  prevent  immense  accumulations  of  cases 
of  pediculosis,  impetigo,  and  the  like  for  the  beginning  of 
the  school  term.  The  salary  of  the  only  head  nurse,  or 
supervisor  of  nurses  (in  Boston),  is  $1,500.*  She  and  the 
other  nurses  are  on  a  salary  schedule  which  rises  with  years 
of  experience  and  growing  skill.  This  latter  desirable 
measure  tends  to  put  the  nurses  on  the  same  professional 
plane  as  the  teachers.  The  tendency  is  for  the  nurse's 
salary  to  be  as  high  as  that  of  the  teacher.  Her  work  is 
perhaps  a  little  longer  but  on  the  average  her  professional 
training  and  years  of  preparatory  schooling  are  much  less. 
Her  night  work  also  is  probably  very  much  less  than  that 
of  teachers. 

The  average  salary  in  the  25  cities  is  $756  while  the 
median  is  $750,  for  ten  months.  A  number  of  nurses  are 
paid  for  an  extra  month  in  the  summer  over  this  sum. 

*More  now. 


92      SCHOOL  HEALTH  ADMINISTRATION 

d.  Total  for  all  Medical  Supervision  Salaries 
The  total  for  all  salaries  of  doctors  and  nurses  is  given 
in  column  25.  The  seeming  discrepancy  for  Newark  arises 
from  the  fact  that  until  February  of  the  school  year,  1910 
1911,  there  were  16  doctors  on  a  salary  of  $400  a  year, 
ten  hours  a  week;  while  after  that  date  there  were  37  doctors 
on  a  salary  of  $300  a  year,  ($  .75  an  hour)  giving  the 
same  time.*  In  three  cases,  as  shown  (Montclair,  Cam- 
bridge, and  Lowell),  the  Boards  of  Health  have  employed 
other  physicians  to  inspect  the  parochial  schools.  The 
physicians  of  no  Board  of  Education  as  yet  inspect  private 
and  parochial  schools.  The  Boards  of  Health  have  exer- 
cised such  rights  because  their  general  health  powers  are 
so  great.  Where  state  laws  require  medical  inspection 
of  parochial  schools,  the  latter  are  coming  to  ask  boards 
of  education  to  do  it,  however. 

2.    SUPPLIES   AND  OTHER  EXPENDITURES 

a.  Carfare.     (Column  26.) 

As  physicians  frequently  have  automobiles  or  other  con- 
veyances, they  are  not  usually  given  car  tickets.  The 
nurses  are  nearly  always  given  such  tickets.  In  some  cases, 
e.g.,  the  small  towns  near  Boston  or  New  York,  railroad 
fare  is  also  included  whenever  a  nurse  takes  a  pupil  or  a 
group  of  pupils  in  to  a  free  clinic  or  specialist.  Permission 
is,  of  course,  granted  by  the  parents  for  such  cases.  The 
median  allowance  for  carfare,  so  far  as  it  could  be  dis- 
covered, seems  to  be  about  thirty-five  dollars  a  year  for 
each  nurse.  The  35  nurses  in  Boston  required  only  $408.50 
for  the  year,  an  average  of  less  than  $12.00  each  ($11.66)  ; 
and  this  sum  includes  the  supervisor  who  probably  spent 
far  more  on  the  average  than  the  other  nurses.  Where  a 
large  city  is  well  districted  and  there  are  many  nurses,  such 
expenditure,  will  be,  of  course,  largely  reduced. 

b.  Printing 

The  printing  expenditures  (Column  27)  are  for  medical 
supervision  blank  forms,  notices  to  parents,  and  the  like. 
Where  daily  reports  are  made  on  printed  postal  card  forms 

*From  February  1st,  1912,  there  have  been  thirty-eight  doctors  on 
a  salary  of  $400  a  year  each,  a  rate  of  about  one  dollar  an  hour. 


THE   TWENTY-FIVE    CITIES  93 

or  sent  in  stamped  envelopes,  postage  becomes  a  large  item. 
In  Newark,  counting  180  school  days,  for  45  medical 
assistants  (doctors  and  nurses)  and  two  cents  for  each  daily 
report,  the  item  amounts  to  about  $162.  This  cost  is 
included  in  this  column.  Meriden,  the  seventh  city,  hap- 
pens to  show  the  initial  cost  of  printing,  when  the  system 
was  started.  After  a  system  has  been  well  started  and  a 
reasonable  supply  of  materials  laid  in,  little  needs  to  be 
paid  for  further  printing.  Where  poorly  considered  forms 
have  been  printed  in  quantities,  great  amounts  of  obsolete 
forms  and  waste  of  money  accumulate.  Certain  cities  have 
so  many  different  forms  that  the  whole  system  is  confusing, 
and  doctors  spend  almost  as  much  and  even  more  time  in 
making  the  daily  reports,  in  their  school  time,  as  in  inspect- 
ing or  examining  children.  For  a  city  of  about  thirty  to 
fifty  thousand  population  the  cost  of  introducing  a  com- 
plete system  of  blank  forms,  nurses'  equipment,  etc.,  need 
not  be  much  over  $200. 

c.  Medical  Supplies 

The  cost  of  medical  supplies  (Column  28)  varies  very 
greatly  because  of  the  great  variance  of  opinion  on  treat- 
ments. Some  hold  that  the  schools  have  no  business  in  this 
field  while  others  contend  that  free  treatment  is  not  any 
worse  and  just  as  desirable  as  free  books  and  free  school- 
houses,  especially  since  we  have  compulsory  attendance  and 
so  compulsory  danger  of  infection  and  unhealthful  school 
environment.  Some  cities  have  such  supplies  in  large  quan- 
tities kept  at  the  central  school  supply  center  and  deliver 
them  when  needed,  on  requisitions  from  the  principals. 
Others  keep  all  the  supplies  in  the  separate  schools;  while 
some  have  the  only  supplies  used  in  the  nurse's  bag  (e.g., 
New  Haven)  which  she  carries  from  school  to  school, 
Again,  some  cities  buy  as  the  supplies  are  needed  from  the 
local  druggists  while  others  buy  for  a  year  at  a  time  from 
wholesale  medical  supply  houses,  choosing  the  lowest  bidder. 
Very  little  study  by  school  business  managers  and  others 
has  been  made  of  the  most  efficient  buying  in  this  field. 
Buying  of  local  druggists  seems  to  be  quite  expensive  as 


94      SCHOOL  HEALTH  ADMINISTRATION 

items  are  overcharged.  The  investigator  found  in  one  city, 
for  example,  twenty-five  cent  hair  brushes  (for  vermin 
cases)  sold  at  $1.50  each.  Most  supplies  keep  well  enough 
to  be  purchased  for  a  year  ahead,  and  this  seems  to  be  the 
best  method,  if  the  requisitions  are  made  out  with  sufficient 
care  and  real  public  bidding  by  the  best  firms  is  solicited. 
A  list  of  the  principal  supplies  found  necessary  in  the  most 
progressive  school  systems  will  be  given  later.  The  cost 
of  such  supplies  in  the  most  liberal  cities  is  comparatively 
very  little.  In  these  twenty-five  cities  the  expenditure  ranges 
from  about  zero  to  nearly  three  thousand  dollars  (New- 
ark) .  The  tendency  will  inevitably  be  in  the  direction  of 
increasing  the  amount  of  free  treatment.  The  writer's 
judgment  on  the  matter  will  be  found  in  the  tentative 
standard  plan  offered  for  criticism  in  the  last  chapter. 

3.    TOTAL    EXPENDITURES    FOR    PUBLIC    SCHOOL   MEDICAL 

INSPECTION 

The  total  expenditures  for  Medical  Inspection  in  the 
schools  studied  are  given  in  column  29.  In  cases  where  the 
cost  of  supplies  and  other  items  could  not  be  separated  from 
general  expenditures,  the  expenditures  would  be  somewhat 
larger.  Where  the  Board  of  Health  has  the  school  physi- 
cians and  the  Board  of  Education  the  nurses,  numbers 
above  are  those  for  the  latter,  and  those  below  for  the 
former.  The  relationship  of  these  expenditures  to  the  total 
running  expenses  of  the  schools  is  given  in  column  53.  The 
general  correlation  with  total  school  expenditures  can  be 
seen  from  inspection  to  be  very  slight,  as  has  before  been 
pointed  out  in  another  connection. 

D.  Management  of  Medical  Supervision  Work. 

I.    TIME    EMPLOYED    BY    DOCTORS    AND    NURSES 

The  school  nurse,  as  suggested,  works,  on  the  average, 
five  and  a  half  days  a  week,  giving  seven  to  eight  hours  a 
day  on  school  days  and  three  to  four  on  Saturday.  Her 
total  weekly  hours  are,  therefore,  very  much  in  excess  of 
the  time  put  in  by  the  average  physician.  In  actual  hours 
the  average  weekly  time  in  hours  of  the  physicians  is  to 


THE    TWENTY-FIVE    CITIES  95 

the  average  of  the  nurses  in  these  twenty-five  cities  as  i  to 
7  or  8.  This  ratio,  by  a  coincidence,  is  that  often  given  by 
those  in  charge  of  such  work  as  to  the  relative  worth  to 
the  schools  of  doctors  and  nurses.  When  a  system  has  been 
properly  organized,  however,  the  physician  will  do  only  such 
highly  skilled  work  as  the  nurse  cannot  do,  and  for  the 
same  amount  of  time  the  ratio  will  be  smaller.  Fortunately, 
the  most  common  ailments  of  school  children  are  so  simple 
that  they  can  be  easily  and  efficiently  handled  by  the  well- 
trained  nurse.  There  is  no  such  responsibility  for  life  and 
limb  as  the  physician  carries  when  he  takes  his  cases  in  pri- 
vate life.  For  the  nurse,  there  is  nearly  always  the  family 
physician  or  dispensary  to  check  up  her  management  of 
cases.  The  disadvantages  of  having  physicians  call  at 
schools  only  once  or  twice  a  week,  cultivating  their  private 
practice  on  other  days  at  the  regular  school  time,  are  so 
great  and  so  numerous  that  it  is  being  found  best  to  have 
them  go  to  the  schools  at  the  same  time  every  school  day. 
As  will  be  shown  later  there  is  also  a  decided  advantage 
in  having  the  time  spent  by  the  physicians  in  the  schools  not 
less  than  two  hours.  And  further,  in  this  connection,  in 
order  to  save  the  vast  amount  of  time  lost  in  traveling  from 
school  to  school  on  any  one  day,  it  will  be  found  more 
efficient  to  have  the  physician  visit  only  one  school  a  day; 
perform  only  the  technical  part  of  the  annual  examinations; 
and  spend  all  of  the  two  hours  or  more  required  in  the  one 
school,  visiting,  perhaps,  five  schools  in  the  five  days.  The 
time  for  physicians  each  day  should  begin  about  ten  min- 
utes before  school  begins,  so  they  may,  in  the  schools  where 
they  examine,  individually  inspect  such  pupils,  also,  as  have 
been  out  of  school  for  several  days  or  such  as  seem  to  the 
teachers  or  nurses  to  require  immediate  and  skilled  atten- 
tion at  the  opening  of  school. 

2.    CHECKS    ON   THE   WORK   OF   MEDICAL   SUPERVISORS 

School  Physicians.  No  very  efficient  and  entirely  satis- 
factory checks  on  the  work  of  physicians  have  yet  been 
devised.  Supervisors  who  have  had  experience  in  medical 


96      SCHOOL  HEALTH  ADMINISTRATION 

inspection  work  realize  most  the  importance  of  devices  for 
obtaining  regularity  and  punctuality  as  well  as  accuracy  of 
reporting  and  conscientiousness  of  pupil  examination.  The 
work  is  often  looked  upon  as  a  "public  plum"  to  be  had  for 
the  picking — a  little  necessary  money  and  very  little  work. 
The  schemes  devised  for  appearing  to  be  at  schools  where 
they  have  done  no  work  by  physicians  who  have  been  turned 
off  or  reprimanded  are  startling  in  the  extreme.  One 
Board  of  Health  officer  said  if  he  had  his  way  he  would 
turn  off  all  his  inspectors  but  one,  but  politics  kept  them  in, 
though  inefficient. 

The  checks  at  Newark  are  interesting  and  seemingly 
quite  effective.  Physicians  are  carefuly  selected  by  the 
supervisor  with  the  help  of  a  written  examination.  Further- 
more the  supervisor  (Dr.  Geo.  J.  Holmes)  frequently 
visits  the  schools  and  sees  the  inspectors  at  work.  There 
are  also  monthly  meetings  of  all  doctors  and  nurses  with  the 
supervisor.  But  the  checks,  proper,  come  in  the  following: 

1.  A  daily  report  of  work  done,  in  detail. 

2.  Occasional  telephone  calls  to  physicians  or  nurses  at 
the  schools,  on  business. 

3.  A  schedule  of  visitation,  so  each  doctor  knows  where 
he  is  expected  to  be  at  any  time. 

4.  Principals'  reports  on  the  work  of  doctors. 

5.  Physician  must  sign  a  book  in  the  principal's  office  on 
coming  to  the  school  and  on  leaving,  and  must  give  the  time 
spent,  in  his  daily  report. 

6.  A  monthly  summarized  report. 

7.  Conferences  with  teachers   and  nurses  on  their  co- 
operation with  the  physicians. 

8.  Requirement  of  early  notice  on  days  when  sickness 
keeps  the  physician  (or  nurse)  at  home  so  a  substitute  may 
be  sent,  the  latter  drawing  the  former's  pay. 

The  necessity  for  careful  checking  up  on  physicians  at 
work  in  the  schools  grows  out  of  the  psychological  nature 
of  the  situation.  There  is  a  strong  tradition  that  public 
office  is  a  public  sinecure;  school  work  is  monotonous  and 
uninteresting  to  many;  it  furthermore  interferes  with  the 


THE   TWENTY-FIVE    CITIES  97 

regular  practice  of  the  physician;  and,  finally,  the  pay  is 
small;  so  the  best  and  even  the  most  public-spirited  physi- 
cians are  not,  as  a  rule,  drawn  into  the  work.  Where  a  sys- 
tem of  medical  inspection  has,  for  example,  been  taken 
over  by  the  Board  of  Education  after  having  been  in  the 
hands  of  the  Board  of  Health  for  a  number  of  years,  it  has 
been  found  necessary,  in  order  to  get  real  efficiency  in  the 
work,  gradually  to  dispense  with  the  services  of  practically 
all  physicians  who  had  participated  in  the  old,  shiftless, 
time-serving  system.  A  man  once  habituated  in  such  a 
system  will  not  usually  change  over  into  an  efficient  exam- 
iner or  inspector  under  the  new  order.  It  is  necessary  as 
soon  as  possible  to  get  new  men  and  start  them  in  right. 

The  checks  for  physicians  found  in  these  cities  are 
given  in  column  37  and  are  seen  to  vary  from  zero  and 
so-called  "annual  reports"  down  to  an  elaborate  system  of 
daily  reporting.  The  efficiency  of  the  systems  will,  in  gen- 
eral, be  seen  to  correlate  closely  with  the  shortness  of  the 
period  reported.  Especially  where  there  is  a  very  large 
number  of  physicians  is  this  true.  In  a  small  system  with 
a  superintendent  interested  in  the  efficiency  of  the  work, 
elaborate  checks  and  daily  reporting  are  not  so  necessary. 
Where  in  a  small  sytem  a  supervisor  of  (educational) 
hygiene  is  put  over  the  work,  mere  checks  are  not  so 
important  as  the  need  for  accuracy  of  reporting;  and  this, 
of  course,  is  all  the  way  through  an  important  reason  for 
frequent  reports  carefully  made  out  and  balanced  in  some 
way.  Close  personal  supervision  decreases  the  need  for 
checks. 

There  are  good  arguments  for  either  a  report  sent  in 
daily,  or  a  weekly  report  which  gives  each  day's  work  and 
in  some  way  rounds  out  the  week.  The  latter  is  especially 
desirable  where  there  is  not  an  adequate  central  clerical 
staff  for  summarizing  reports,  and  where  it  is  desired  to 
have  the  doctor's  and  nurse's  reports  sent  in  as  one  sum- 
mary, giving  both  the  number  of  ailments  and  what  was 
done  with  them.  No  city  yet  follows  this  plan.  The  daily 
reporting  systems  now  in  vogue  have  for  the  most  part, 


98      SCHOOL  HEALTH  ADMINISTRATION 

it  seems,  been  devised,  and  are  being  supervised  and  car- 
ried out,  by  men  who  have  been  school  inspectors  and 
know  the  nature  of  the  problem.  Monthly  reporting,  or 
any  reporting  for  a  longer  time  than  a  week  seems  to  lead 
in  most  cases  to  inaccuracy  and  less  careful  work.  I  shall 
try  to  show  this  later  where  the  factors  which  go  to  make 
up  efficiency  are  set  forth  in  figures. 

One  of  the  most  exasperating  sources  of  inefficiency  in 
this  field,  as  suggested,  is  a  complicated  system  of  reporting 
which  tediously  takes  up  much  of  a  physician's  time.  Dr. 
Cornell  shows  the  physician's  side  of  the  matter  quite 
lucidly  in  his  book,  "Health  and  Medical  Inspection  of 
School  Children,"  page  46: 

"In  our  large  cities,  however,  there  is  a  tendency  toward 
too  much  book-keeping  by  the  school  physician,  and  it  is  not 
unusual  for  one-half  or  two-thirds  of  the  medical  examiner's 
time  to  be  consumed  in  the  writing  of  multiple  reports  and 
complex  records.  Many  of  them  are  futilely  devised  to 
take  the  place  of  personal  supervision,  which,  as  has  been 
noted,  is  essential  in  the  conduct  of  miedical  inspection  on 
a  large  scale.  Their  aim  is  not  to  record  useful  facts,  but 
to  check  up  the  inspector's  work  and  personal  honesty. 
Failing  to  do  this,  because  it  is  just  as  easy  to  record  a  false 
entry  four  times  as  it  is  to  record  it  once,  hundreds  of 
dollars  worth  of  stationery  and  thousands  of  dollars  worth 
of  salaries  are  wasted.'' 

Any  system  that  can  be  devised  which  will  save  the 
physician's  time  in  making  reports  and  at  the  same  time 
insure  careful  work  and  accurate  reporting  is  greatly  to 
be  desired.  The  standard  plan  offered  in  a  later  chapter 
dispenses  with  practically  all  reporting  by  the  physician  and 
gives  it  to  the  nurse.  The  nurse  costs  on  the  average  for 
each  hour  of  service  about  $  .50  (38  hours  a  week,  152  a 
month,  at  $75)  ;  while  the  physician  costs,  at  least,  twice 
this  sum.  It  is  poor  scientific  management  which  does  not 
limit  the  physician  to  such  technical  work  as  the  nurse  cannot 
do  well.  The  nurse  can  make  out  reports  for  herself  and 
for  the  physician;  and  she  can  do  much  of  the  other  work 


THE   TWENTY-FIVE    CITIES  99 

which  the  physician  is  now  doing.  The  nurse,  giving  full 
time  to  the  schools,  can,  moreover,  be  held  more  strictly 
to  account  and  will  feel  more  the  whole  scope  and  continu- 
ity of  the  work  if  she  makes  the  combined  report.  In  some 
school  systems  visited  the  nurse  went  her  way  and  the 
physicians  went  their  ways,  each  disregardful,  quite  largely, 
of  what  the  others  were  doing.  They  should  work  as  a 
team,  each  complementing  the  work  of  the  other. 

3.    VISITS  AND  SCHEDULES 

Many  of  the  cities  more  experienced  in  the  work  have 
definite  daily  schedules  for  both  physicians  and  nurses.  For 
nurses,  the  schedule  is  practically  universal.  The  number 
of  schools  assigned  to  each  physician  and  nurse  is  given  in 
columns  41  and  42,  and  the  number  of  pupils  in  columns 
39  and  40,  and  in  later  columns.  Boston  had  a  physician 
for  each  school,  elementary  and  high,  on  the  average, 
and  one  nurse  for  each  two  schools  (now  nearly  as  many 
nurses  as  large  elementary  schools).  Waterbury  has  seven- 
teen schools,  many  quite  small,  for  the  physician;  while 
Providence  has  40  schools  for  the  one  nurse.  Since  many 
or  most  of  the  cities,  excepting  Brockton,  throw  many  ob- 
stacles in  the  way  of  the  nurse  doing  much  work  of  inspec- 
tion, rules  quite  frequently  prohibiting  it  except  for  very 
minor  cases,  it  can  be  seen  that  daily  inspection  of  pupils  at 
all  schools  by  physicians  is  out  of  the  question  in  the  short 
daily  time  in  most  cities.  The  time  would  be  used  up  in 
mere  school  to  school  travel.  Yet  daily  inspection  at  each 
school  is  the  ideal  of  all  these  cities.  The  usual  plea  is  for 
more  physicians  with  which  to  meet  this  condition.  Two 
alternatives  seem  not  to  have  occurred  to  any  city.  First, 
combine  all  the  phases  of  educational  hygiene  into  one  de- 
partment; dispense  with  the  services  of  the  physical  train- 
ing supervisor,  if  any,  and  make  director  of  the  hygiene 
department  for  full  time  a  man  who  is  both  a  physician 
and  a  physical  educator.  This  will  give  correlation  and 
skilled  supervision,  making  easily  possible,  second,  the  limi- 
tation of  physicians  to  such  medical  work  as  cannot  well  be 


ioo    SCHOOL  HEALTH   ADMINISTRATION 

done  by  nurses,  and  the  increase  of  the  powers  of  the  nurses 
so  they  may  do  much  or  most  of  the  work  of  daily  inspection. 
This  is,  however,  the  tendency.  The  Brockton  nurse  uses 
the  physicians  only  for  consultation  purposes;  New  York 
City  (Bureau  of  Municipal  Research  and  Board  of  Health) 
has  demonstrated  that  the  nurses  can  inspect  for  infectious 
diseases  and  in  some  of  the  twenty-five  cities  nurses  have 
found  more  cases  of  infectious  disease  then  have  the  doctors 
(Norwood,  Winchester,  Montclair,  Providence,  and  Bos- 
ton, Cols.  206  and  207).  If  the  nurse  can  make  the  daily 
inspections,  which  are  almost  entirely  for  the  purpose  of 
nipping  epidemics  of  infectious  diseases  in  the  bud,  the 
physicians  need  not  spend  time  traveling  from  school  to 
school,  but  can  go  to  but  one  school  a  day,  five  a  week,  or 
ten  in  two  weeks,  if  desired,  thus  reaching  each  school  once 
a  week,  or  once  in  two  weeks,  on  a  routine  schedule  and  at 
the  same  time  being  on  call  from  the  nurse  in  case  she  is 
perplexed  at  any  other  school.  The  nurse  could  be  on  a 
schedule,  and  when  her  teachers  were  trained  to  detect  the 
symptoms  of  infectious  disease,  she  could  avoid  travel  to 
all  of  her  schools  each  day  by  judicious  use  of  the  telephone. 
(See  the  last  chapter.) 

4.    EXAMINATIONS  AND  INSPECTIONS 

Another  great  source  of  waste  and  confusion  in  this  field 
is  the  almost  universal  failure  to  distinguish  between  making 
a  careful,  complete  physical  examination,  similar  to  or  better 
than  an  insurance  examination,  of  a  pupil,  and  a  very  partial 
examination,  such  as  looking  at  only  the  hair  of  pupils  of 
a  room  or  passing  up  and  down  the  aisles  looking  at  only 
the  hands  and  faces,  for  vermin  or  for  infectious  diseases. 
As  a  consequence,  it  has  been  almost  impossible  for  the 
writer  to  determine  for  each  city  how  many  children  have 
been  given  a  complete  physical  examination.  Some  use  the 
term  "physical  examination"  and  "examination"  to  distin- 
guish but  this  merely  leads  to  confusion.  The  writer  has 
been  driven  to  adopt  for  his  own  use  the  following  defini- 
tions, which  he  recommends  for  standard  usage. 


THE    TWENTY-FIVE    CITIES  10: 

Physical  examination,  or  better,  merely  examination  is  to 
mean  the  complete,  physical  examination  of  a  pupil  to  learn 
his  general  health  condition,  his  physical  defects  and  any- 
thing about  his  physical  make-up  which  will  militate  against 
his  school  or  physical  progress.  The  examination  will  prob- 
ably best  be  made  once  a  year;  and  may  be  made  by  one 
or  more  persons,  preferably,  perhaps,  by  the  nurse  for  vision 
and  hearing  tests  and  any  other  phases  she  can  do  well,  by 
the  medical  examiner  (heart  and  lungs,  adenoids  and  ton- 
sils, and  certain  other  technical  phases),  and,  third,  by  the 
teacher  of  physical  training  (height,  weight,  and  chest  ex- 
pansion if  these  are  thought  desirable  and  required).  To 
this  in  some  schools  (e.g.,  Cleveland)  is  now  added  the 
examiner  for  mental  defects.  Other  systems  have  dental 
examiners  and  oculists.  All  of  these  persons  together  make 
the  single,  annual  examination. 

Inspection  is  a  good  word  to  use  to  mean  any  partial  ex- 
amination outside  of  the  complete  physical  examination.  Our 
first  school  medical  work  was  "medical  inspection"  because 
no  physical  examinations  were  given,  we  might  say.  Any 
looking  at  a  pupil  for  any  special  signs,  or  any  study  of  him 
by  health  officials  apart  from  the  complete  annual  physical 
examination  is  an  inspection.  Cities  are  trying  to  give  each 
pupil  one  (physical)  examination  a  year;  they  may  give  a 
pupil  fifty  inspections  in  a  year  if  he  requires  it.  A  case 
of  pediculosis  may  easily  require  fifty  inspections  before  it 
is  thoroughly  cured.  It  may  have  been  found  first  by  doctor 
or  nurse  at  the  time  of  the  examination. 

If  the  nurse  working  alone  examines  fifty  pupils  today 
as  to  sight  and  hearing,  how  shall  she  record  her  work?  It 
is  only  a  part  of  the  annual  examination.  This  makes  neces- 
sary a  distinction  between  the  "medical"  and  the  "scholastic" 
examination;  or,  she  may  record  so  many  examinations  of 
vision  and  hearing  and  these  can  be  combined  with  the  re- 
port of  the  medical  examinations  by  the  doctor  when  they  are 
made.  This  will  prevent  reports  of  two  or  three  hundred 
or  more  "examinations"  for  from  twenty-five  to  a  hundred 
pupils.  There  can  not  be  more  physical  examinations  than 


102     SCHOOL  HEALTH  ADMINISTRATION 

there  are  pupils  examined.     Re-examinations  can  be  called 
inspections  or  simply  re-examinations. 

Bringing  together  here  the  writer's  classification  of  the 
many  kinds  of  work  being  attempted  in  these  cities  in  the 
field  of  inspection  and  examination  we  should  have  for 
any  city  with  a  fairly  complete  system : 

A.  EXAMINATIONS — complete  physical,  once  a  year. 

1.  Medical,  only  such  phases  as  the  nurse  cannot  do 

well,  by  doctors  and  dentists. 

2.  Scholastic,  vision  and  hearing,  and  perhaps  other 

phases  by  the  nurses.     This  is  now  being  done 
by  teachers  in  three  or  more  of  the  five  states. 
Vision  may  be  tested  by  oculists.    Principals  may 
make  both  tests. 

3.  Anthropological,  height,  weight,  chest  expansion 

and  other  similar  measurements,  by  physical 
training  teachers  or  nurses,  if  required.  They 
are  of  no  value  as  usually  taken,  and  are  practi- 
cally never  used  or  needed  where  well  taken. 

4.  Psychological,   for  suspected  cases  of  mental  de- 

ficiency, or  other  abnormal  mental  conditions. 
5.  Work  Certificate,  probably  not  necessary  in  effi- 
cient systems. 

B.  INSPECTIONS — as  many  a  year  for  any  child  as  he 
needs  to  be  seen,  after  or  before  the  examination — also  used 
for  school  building  and  home. 

1.  September  room-inspection — quick  inspection  of  all 

pupils  at  the  beginning  of  the  school  year  or  term, 
room  by  room,  doctor  and  nurse  working  as  a 
team,  one  medically  inspecting,  the  other  record- 
ing. May  be  had  oftener  if  desired.  If  so, 
they  should  be  called  general,  or  routine  room- 
inspections. 

2.  Occasional  room-inspection,  any  other  room  inspec- 

tion after  the  general  one  in  September;  might 
also  be  called  a  special  room-inspection. 

3.  Individual  inspection — any  inspection  of  a  pupil 


THE   TWENTY-FIVE    CITIES  103 

apart    from    group    inspection — pupils    in    their 

homes,  pupils  returning  after  exclusion  or  other 

absence,    pupils    referred    to    either    doctor    or 

nurse,  etc. 

4.  Home-hygiene  inspection — by  nurses.    Recorded 

on  pupils'  individual  health  record  cards. 
5.  Sanitary  inspection  of  the  school,  or  "school  sani- 
tary inspection."    By  any  competent  person  dele- 
gated for  this   work.      Recorded  on   a   special 
school  sanitation  record  card  for  each  school, 
such  as  is  used  by  the  Philadelphia  Board  of 
Health.     See  Burks'  "Health  and  the  School," 
pages  187-8. 

With  this  distinction  between  inspection  and  examination 
in  mind  it  is  possible  to  see  where  most  cities  stand  in  this 
matter  and  to  determine  whether  they  have  merely  "medical 
inspection"  systems  or  something  broader  and  more  educa- 
tional which  the  writer  frequently  calls  "Medical  Super- 
vision" for  want  of  a  better  term.  Health  Supervision  has 
been  suggested,  but  this  is  bad  in  that  all  phases  of  educa- 
tional hygiene  are  really  Health  Supervision.  Health  In- 
spection is  weak  at  both  ends,  as  a  term.  Cities  with  no 
physical  examinations  are  medical  inspection  systems;  those 
having  examination  require  a  broader  term.  There  seem  to 
be  only  two  disadvantages  in  the  adoption  of  the  term  Medi- 
cal Supervision,  namely,  that  "Medical  Inspection"  is  the 
term  now  used  in  most  cities  and  state  laws,  and  that  directors 
of  different  phases  of  school  work  are  usually  called  "super- 
visors," e.g.,  Supervisor  o'f  Drawing;  and  Supervisor  of 
Medical  Supervision  does  not  make  a  very  good  term.  He 
may,  of  course,  be  called  director  of  hygiene  if  head  of  the 
whole  department  of  school  health,  or  "director"  of  medical 
supervision,  if  not.  On  the  other  hand,  a  good  term  can  be 
helped  to  win  its  way;  and  only  in  the  largest  cities  will  there 
need  to  be  directors  of  medical  supervision,  for  in  smaller 
cities  the  general  health  and  physical  development  super- 
visor in  whose  department  medical  supervision  is  but  one  di- 
vision, can  be  termed  Director  (or  Supervisor)  of  Hygiene. 


io4    SCHOOL  HEALTH  ADMINISTRATION 

Since  medical  inspection  is  only  part  of  the  school  medical 
work,  it  is  very  awkward  and  unfortunate  to  use  it  as  part 
of  the  term  covering  all  school  medical  work,  as  is  now  so 
often  done.  Considerable  reflection  on  the  already  fixed 
character  of  medical  "inspection"  in  state  laws  and  common 
thought  leads,  however,  to  its  reluctant  use  here.  We  shall 
hereafter  use  the  term  medical  inspection.  After  this  analysis 
and  classification  of  school  medical  work,  we  can  look  at  the 
tables  to  see  at  what  stage  our  cities  stand,  from  mere  in- 
spection for  infectious  diseases,  very  few  of  which  ailments 
are  found  in  schools,  up  to  all-round,  effective  medical  pro- 
visions, including  annual  examinations  and  frequent  inspec- 
tions for  all  pupils,  and  putting  the  emphasis  upon  cures  and 
prevention  instead  of  merely  finding  "cases." 

5.    NUMBER  OF  PUPILS   FOR  EACH  DOCTOR  AND  NURSE 

The  number  of  children  supervised  by  each  doctor  and 
nurse  depends  upon  the  kind  of  system,  from  mere  inspection 
for  infectious  diseases  up  to  the  most  intensive  kind  of  edu- 
cational health  work  and  consequently  fewer  children,  and 
upon  the  degree  of  development  of  the  system.  Many  school 
systems  start  out  with  a  few  doctors  and  nurses  in  the  hope 
of  later  obtaining  an  adequate  number.  The  great  danger 
here  is  that  the  first  tentative  steps  may  be  taken  as  a  per- 
manent standard,  just  as  emergency  and  monitorial  teaching 
of  fifty  to  eighty  pupils  in  a  school  room  has  grown  into 
established  custom  in  many  places.  The  number  of  children 
for  each  doctor  and  nurse  is  given  for  elementary  children 
for  the  reason  that  most  of  the  cities  give  very  little  or  no 
attention  to  high  school  pupils  in  this  particular. 

The  reasons  given  for  the  neglect  of  the  high  schools  are 
as  follows: — 

a.  Most  medical  work  is  found  in  the  first  four  or  five 
grades  of  the  schools.    Very  little,  comparatively,  is  found  in 
the  upper  grades  and  high  school. 

b.  High  school  students  belong  to  a  social  class  that  does 
not  respond  well  to  the  efforts  of  doctors  and  nurses.    Fur- 


THE    TWENTY-FIVE    CITIES  105 

thermore,  the  pupils  are  older  and  better  able  to  care  for 
themselves  and  to  obtain  private  medical  service. 

c.  High  school  teachers  are  not  so  helpful  as  are  the 
elementary  teachers  in  referring  ailing  and  defective  pupils. 

d.  Departmental  work  in  the  high  schools  makes  room- 
inspection  of  pupils  more  difficult. 

e.  The  physical  training  directors  of  the  high  school  in 
certain  cases  call  the  attention  of  pupils  to  ailments  or  de- 
fects urging  attention  by  the  individual  pupil  or  by  family 
physician,  especially  in  the  few  fortunate  places  where  such 
teachers  are  also  physicians. 

/.  The  age  of  the  high  school  pupils  makes  them  more 
sensitive  and  reticent.  Cities  (e.g.,  Newark)  that  have 
tried  to  give  adequate  and  thorough  medical  examinations  by 
baring  pupils  to  the  waist  have  had  some  trouble  in  carrying 
the  work  on.  All,  however,  have  not. 

The  best  example  of  what  need  there  is  in  high  schools 
for  medical  supervision  and  what  can  be  accomplished  there, 
has  perhaps  best  been  shown  by  Prof.  Thos.  Storey,  M.D., 
in  charge  of  the  gymnasium  at  the  College  of  the  City  of 
New  York  and  the  high  school  connected  with  it.  (See 
report  of  this  work  in  the  next  chapter.  Dr.  Storey  shows 
that  medical  work  in  the  high  school  is  of  very  great  im- 
portance and  that  very  much  can  be  accomplished  in  the 
way  of  cures.) 

The  neglect  of  the  high  school  and  even  the  fifth  to  the 
eighth  grades  by  many  of  the  twenty-five  cities  studied  (only 
three  or  four  having  done  anything  at  all  with  the  high 
school  problem)  makes  it  necessary  to  base  computations  as 
to  the  number  of  children  for  each  doctor  and  nurse  on  the 
number  of  elementary  pupils.  These  numbers  are  given  in 
columns  39  and  40.  For  physicians,  the  average  number  of 
pupils  each  ranges  from!  about  651  in  Montclair  to  12,077  in 
Waterbury.  Since  the  physicians  give  irregular  time,  how- 
ever, it  is  necessary  to  use  the  "equated  physician"  unit  which 
takes  into  consideration  the  number  of  hours  a  week  the 
physician  works.  The  number  of  pupils  for  each  equated 
physician  is  given  in  column  43  with  the  number  of  schools 


io6    SCHOOL  HEALTH  ADMINISTRATION 

for  each  in  column  42.  The  average  number  of  elementary 
pupils  for  each  physician  on  this  basis  is  3,407  and  the 
median  number  1,631. 

The  number  of  elementary  pupils  for  each  nurse  ranges 
from  1088  up  to  15,702. 

Where  the  physician  is  unnecessarily  called  upon  to  make 
vision  and  hearing  tests,  to  count  the  number  of  decayed 
teeth  with  the  use  of  a  tooth  mirror  requiring  sterilization 
for  each  child,  to  make  anthropological  measurements  of 
height,  weight,  chest  expansion,  etc.,  and,  finally,  to  make 
out  duplicate  or  triplicate  cards  of  several  varieties,  forms 
and  colors,  it  can  be  seen  that  fewer  children  can  be  handled 
in  a  year  by  each  physician  than  in  a  more  efficient  system 
which  eliminates  much  of  this  labor  or  gives  it  to  the  lower 
salaried  and  full-time  nurse. 


CHAPTER  V 
THE  NATURE  AND  EFFICIENCY  OF  THE  WORK  DONE 

AFTER  a  study  of  the  agents  of  medical  inspection,  their 
number,  their  cost,  and  their  administration,  comes  naturally 
the  problem  of  their  accomplishment.  The  work  of  medical 
inspection  in  public  schools  easily  divides  into  ( i )  the  finding 
of  the  children  who  need  medical  attention,  (2)  getting  them 
cured  of  their  ailments  and  defects,  and  (3)  preventive 
measures  for  making  the  former  effort  unnecessary.  To 
make  a  simple,  adequate  classification,  statement  and  test  of 
the  heterogeneous  work  now  being  done  in  these  twenty-five 
cities,  with  their  reports  of  all  degrees  of  completeness  and 
accuracy,  is  a  task  at  present  practically  impossible.  What 
is  here  presented  is  only  a  beginning  and  cannot  lay  claim  to 
very  great  accuracy  or  finality.  The  hope  is  that  certain 
general  tendencies  may  be  brought  out  and  that  future  in- 
vestigations of  this  subject  may  be  made  more  easily.  We  are 
interested  here  not  so  much  in  the  purely  medical  or  purely 
scientific  aspects  of  the  problem  as  in  the  actual  administra- 
tion and  its  improvement. 

In  general,  it  may  be  said  that  the  physicians,  nurses  and 
teachers  find  the  ailing  pupils,  the  nurses  do  most  in  getting 
treatments  and  cures,  while  there  are  no  single  preventive 
agents  unless  we  might  mention  here  the  physical  training 
teachers,  the  teachers  in  open-air  schools,  and  a  few  others. 
As  a  brief  introduction  to  the  following  tables  setting  forth 
the  work  done  we  shall  give  some  of  the  generalizations 
which  developed  while  traveling  about  from  city  to  city  study- 
ing this  work: — 

a.  The  focus  of  attention  in  most  medical  inspection  sys- 

107 


io8     SCHOOL  HEALTH  ADMINISTRATION 

terns  is  not  on  prevention  and  cure  but  on  the  finding  (in- 
specting) of  the  cases.  When  asked  for  the  purpose  of  the 
medical  inspection  work,  in  only  one  or  two  cases  out  of  many 
have  school  physicians  emphasized  getting  and  recording 
treatments  and  cures.  Even  though  all  these  cities  have 
nurses,  therefore,  it  is  impossible  from  most  reports  or  any 
other  records  to  show  the  real  efficiency  of  medical  inspection 
in  the  amelioration  of  health  conditions. 

b.  Most  medical  inspection  is  "inspection"  and  little  more. 
Very  few  cities  give  complete  physical  examinations  to  even  a 
part  of  the  children  each  year.  South  Manchester  is  prob- 
ably the  only  city  that  examined  all  school  children  in  the 
school  year  studied,  and  exceedingly  few  examine  high  school 
pupils.  The  word  "examination"  as  related,  is  often  used 
for  inspection :  an  incomplete  physical  study  of  a  child,  usu- 
ally for  only  a  few  symptoms  like  those  of  infectious  dis- 
eases, pediculosis,  or  cleanliness.  Further,  teachers,  nurses, 
and  physical  training  teachers  often  make  the  parts  of  an  ex- 
amination, especially  those  relating  to  vision  and  hearing,  and 
this  has  complicated  matters.  In  some  cases,  too,  voluntary 
agents  have  come  in — dentists  especially — and  have  made 
the  oral  and  teeth  examinations.  Most  physicians  and  nurses 
met  distinctly  favored  one  complete  physical  examination 
for  each  elementary  and  high  school  pupil  in  the  school  sys- 
tem annually,  but  did  not  unanimously  think  it  feasible  to  at- 
tempt it  where  there  was  but  a  small  inadequate  force.  Only 
certain  deep-lying,  incipient,  or  insidious  ailments  are 
missed  when  there  is  careful  "inspection"  without  the  annual 
examination.  The  more  serious  heart,  lung,  nervous  or  di- 
gestive system  ailments,  vision  and  hearing  defects,  adenoids, 
and  the  like,  are  frequently  suspected,  and  the  pupils  re- 
ferred to  family  physicians  or  dispensary  without  it.  The 
importance  of  the  many  cases  missed,  however,  is  the  reason 
for  the  thorough  and  complete  examination.  To  repeat,  we 
shall  use  here  the  term  "examination"  to  refer  to  the  single 
complete  study,  often  made  by  more  than  one  person,  and 
the  term  "inspection"  to  refer  to  any  medical  study  or  look- 
ing at  the  child  outside  of  this  examination. 


EFFICIENCY  OF  HEALTH  WORK         109 

c.  The  difficulty  of  accurately  recording  the  total  number 
of  children  examined  and  inspected  with  the  number  of  new 
cases  found  and  the  number  of  inspections  ("old  cases") 
that  were  necessary  to  get  these  cases  treated  and  cured  has, 
with  the  poor  record  forms  in  use,  made  it  impossible  in 
most  cities  to  discover  how  many  cases  of  any  one  ailment 
were  found,  treated,  or  cured  or  how  many  children  were  at 
any  given  time  or  at  the  end  of  the  year  affected  with  a 
certain  ailment.  When  the  physician  gives  a  list  of  "cases" 
we  cannot  tell  whether  these  are  the  same  which  the  doctor 
has  found  or  new  ones  or  how  many  of  these  "cases  seen" 
represent  a  single  child.  A  child  with  pediculosis  may  be 
seen  several  times  by  the  physician  and  twice  or  three  times 
a  week  for  several  months  by  the  school  nurse  or  janitress; 
yet  there  has  been  but  one  case  or  child.  A  case  of  defective 
vision  may  be  seen  once  by  the  nurse  or  doctor  and  never 
again  recorded.  Until  clear  distinctions  are  made  between 
these  matters  in  more  efficient  reports,  medical  inspection  (or 
supervision)  will  be  on  a  hearsay,  theoretical  basis  and  there 
will  exist  both  the  greatest  enthusiasm,  and  ungrounded 
belief  in  its  wonder-working  influence  upon  school  and  com- 
munity progress  alongside  of  the  greatest  indifference  and 
skepticism  as  to  its  utility. 

To  obtain  adequate  reporting  and  accurate  data,  the  ail- 
ments, new  and  old,  found  by  the  physician  should  be  placed 
side  by  side  with  those  found  by  the  nurse  in  such  a  way  to 
show  exactly  how  many  new  ailments  were  found  altogether, 
how  often  they  were  re-inspected  and  what  was  the  outcome. 
It  would  be  well  if  a  plan  could  be  devised  whereby  one  per- 
son, the  nurse,  could  do  all  the  reporting  on  a  single  form.* 
In  the  following  tables  the  work  of  the  doctor  and  nurses 
for  each  ailment  is  listed  together,  but  the  distinctions  men- 
tioned could  not  be  made  except  for  one  or  two  cities. 

These  facts  should  make  us  cautious  about  making  dog- 
matic statements  about  the  number  of  children  affected  with 
various  ailments  in  these  cities  or  the  country  at  large. 


*See  author's  plan  in  the  last  chapter. 


no    SCHOOL  HEALTH  ADMINISTRATION 

d.  Doctors,  for  the  most  part,  record  only  the  cases  that 
are  printed  on  the  record  cards  or  report  sheets.    They  will 
not,  usually,  take  time  to  write  in  the  names  of  the  cases  not 
named  in  the  report.    This  has  been  proved  in  a  number  of 
satisfactory  ways.    It  throws  light  not  only  on  the  following 
tables  but  on  the  kind  of  record  cards  and  reports  which  are 
necessary  to  get  the  best  results.    They  must  give  all  the  dif- 
ferent ailments  and  be  very  simple  and  convenient.     The 
seventeen  ailments  making  up  90  per  cent  of  the  cases  found 
in  all  cities  (Table  IX)   are  not  those  appearing  on  record 
cards  and  reports.    By  the  use  of  our  classification  of  school 
ailments  on  the  report  forms,  however,  we  can  obviate  the 
printing   of   a   necessarily   limited  list  of   ailments   on  the 
individual  record  cards. 

e.  Although  school  inspection  by  doctors  was  started  by 
boards  of  health  to  keep  down  epidemics  of  infectious  dis- 
eases through  the  exclusion  of  germ-carrying  children,  on  the 
theory  that  the  school  was  the  chief,  if  not  practically  the 
only  place  of  spread,  nevertheless,  comparatively  few  cases 
of  infectious  disease  are  found  in  the  schools,  and  the  amount 
of  spread  at  school  is  seriously  questioned.     Mothers  rarely 
are  wrong  in  their  interpretation  of  the  children's  condition, 
and  keep  the  children  at  home  so  the  ailments  cannot  be 
found  at  school.    The  first  notice  the  school  gets  in  the  usual 
system  is  the  report  of  the  board  of  health  on  quarantine. 
Children  are,  however,  sometimes  found  who  have  returned 
to  school  too  early.    The  surprise  is  in  the  small  number  of 
cases  found  in  school  in  proportion  to  the  number  which  actu- 
ally existed.    Table  IX  gives  the  actual  number  of  ailments 
found,  and  the  probable  true  number  for  the  54  classes  of 
ailments. 

/.  There  is  a  great  lack  of  correlation  and  integration 
among  the  various  phases  of  hygiene  in  the  school  systems 
which  have  adopted  medical  inspection.  The  proper  kind  of 
organic  unity  will  probably  not  come  in  the  health  work  for 
most  cities  until  a  full-time  physician,  physical-educator  is 
made  director  of  all  school  health  provisions.  Only  then  will 
there  be  real  supervision,  careful  work,  adequate  reporting, 


EFFICIENCY  OF  HEALTH  WORK         in 

and  testing  of  results.  If  this  dissertation  does  no  more  than 
to  emphasize  this  need  it  will  have  served  a  worthy  purpose. 
Such  a  director  can  now  be  obtained  at  a  salary  of  about 
$3,000,  but  the  added  cost  need  not  be  so  great  because  in 
most  cases  one  or  more  physical  training  teachers  and  several 
part-time  physicians  can  be  dispensed  with.  The  recom- 
mended plan,  as  well  as  the  needed  number  of  directors, 
physicians  and  nurses  with  salaries  (Table  XII)  is  given 
later.* 

g.  Very  much  dependence  is  placed  upon  the  teachers  in 
inspecting  the  children  for  ailments  and  referring  them  to 
the  doctors  and  nurses.  In  many  cases  it  may  almost  be  said 
that  the  chief  function  of  the  physician  has  been  to  remind 
the  teachers  to  look  for  the  ailments,  when  the  bell  was  rung, 
announcing  his  presence  in  the  building.  Where  there  is  no 
annual  routine  inspection  nor  examination  of  all  children  the 
inspection  has  been  more  truly  teacher  inspection  than  medi- 
cal inspection.  So  we  shall  find  a  teacher  bias  in  the  tables 
following.  The  need  of  inspection  of  the  teachers,  and  of 
their  training  in  this  work  in  their  professional  courses  and 
in  their  classrooms  is  very  much  neglected,  to  the  great  edu- 
cational and  economic  loss  to  schools  and  teachers. 

h.  Teeth  and  such  minor  ailments  are  frequently  given 
little  notice  by  physicians,  partly  because  their  practice  has 
omitted  this  element  of  health  and  partly  because  they  find 
it  of  little  value  to  record  defective  teeth  when  there  is  no 
school  dental  clinic  or  other  adequate  free  agency  for  put- 
ting teeth  in  repair.  Yet  defective  teeth  are  probably  the 
chief  source  of  many  of  the  worst  ailments  of  childhood 
and  youth,  not  to  mention  later  life.  The  words  of  the  great 
Osier  are  familiar:  "If  I  were  asked  to  say  whether  more 
physical  deterioration  was  produced  by  alcohol  or  by  defec- 
tive teeth,  I  should  unhesitatingly  say  by  defective  teeth." 

i.  If  the  writer  were  asked  which  of  the  ailments  in  the 

*See  also  the  article  on  this  subject  by  the  writer  in  the  New 
England  Journal  of  Education  for  Feb.  27,  1913,  the  address  at  the 
1913  N.  E.  A.  convention  and  the  address  at  the  1913  meeting  of  the 
International  School  Hygiene  Congress. 


ii2     SCHOOL  HEALTH  ADMINISTRATION 

following  tables  had  taken  up  most  time  of  the  doctors  and 
nurses,  which  had  actually  absorbed  most  of  the  expenditure 
for  medical  inspection,  he  should  unhesitatingly  reply  with 
the  horrid  word — lice.  A  child,  especially  a  girl  with  her 
long  hair,  may  be  cured  of  this  ailment  a  dozen  times  a  term 
and  still  have  it.  One  doctor  on  a  comparatively  very  large 
salary  spent  most  of  his  time  during  the  year  in  going  down 
the  aisles  of  classrooms  from  the  rear,  using  a  small  hand 
glass  with  which  to  spy  out  nits  and  other  signs  of  vermin 
(pediculosis).  His  theory  was  that  if  children  are  taught 
to  rid  themselves  of  these  larger  parasites  they  will  be  better 
ready  to  accept  the  germ  theory  of  disease  and  act  upon 
it.  The  recent  studies  pointing  to  the  larger  parasites  as 
the  carriers  of  disease  germs  [the  tick  of  spotted  fever,  the 
louse  of  typhus  fever  and  perhaps  other  contagious  diseases, 
not  to  mention  the  analogous  work  of  the  flea  for  bubonic 
plague  or  Black  Death,  the  mosquito  for  malaria  and  yel- 
low fever,  the  stable  fly  (Stomoxys)  for  the  infection  of 
infantile  paralysis  (Poliomyelitis),  and  the  house  fly  for 
various  summer  ailments,  especially  ravaging  infancy],  all 
would  strengthen  this  point  of  view. 

While  the  theory  is  probably  sound,  the  administrative 
question  here  is :  "Would  it  not  be  far  more  economical  and 
just  as  good  service  if  the  city  were  to  use  the  money  to 
employ  two  nurses  on  full  time  for  such  work  instead  of  the 
one  part-time  physician  at  $1,200?" 

Another  interesting  fact  in  this  connection  is  that  medical 
inspection  was  put  into  the  school  of  one  small  town  (South 
Manchester)  in  1905  in  the  hope  that  the  schools  would 
soon  be  delivered  of  this  parasitic  plague  (pediculosis)  ;  but 
even  with  the  help  of  the  nurse,  the  trouble  has  not  been  by 
any  means  eliminated,  an  irreducible  minimum  seeming  to 
remain  of  those  who  furnish  the  parasites  to  others.  The 
table  shows  a  decrease  in  the  number  of  children  inspected 
as  well  as  the  number  of  times  ailing,  so  the  number  has 
hardly  decreased  as  rapidly  as  it  appears. 


EFFICIENCY  OF  HEALTH  WORK         113 

Total 
Number 

Pupils  Cases  of  No.  Pupils 

"Examined."  Pediculosis.  Excluded. 

First  year 421  216  150 

Second  year 458  282  135 

Third  year    477  227  I25 

Fourth  year    342  96  108 

Fifth  year   318  84  89 

Sixth  year   117  66  55 

"Examined"  here  means  referred  cases  inspected. 
(Physical)  examinations,  one  a  year  for  each  pupil,  were 
begun  in  the  year  of  this  study.  While  there  has  been  an 
increase  in  school  population,  there  has  been  a  decrease  in 
cases  reported  and  in  the  number  of  exclusions.  It  would 
be  interesting  to  know  whether  the  inspector  has  changed  the 
meaning  of  "case"  as  time  went  on,  and  if  standards  of  ex- 
clusion are  not  changing.  The  reports  of  this  city  should  be 
followed  up  to  see  if  the  ailment  is  eliminated. 

GENERAL  EFFICIENCY  OF  THE  MEDICAL  INSPECTION  SERVICE 

Let  us  turn  our  attention  first  to  the  general  accomplish- 
ment by  the  entire  school  medical  service,  and  examine 
table  VII  which  gives  a  bird's-eye  view  of  this  field.  In 
order  to  separate  unlike  elements  and  to  make  clear  what  is 
actually  being  done,  we  have  been  driven  to  certain  defini- 
tions which,  we  hope,  may  be  of  value  not  only  for  the 
purposes  of  this  study,  but  also  in  actual  school  administra- 
tion. The  first  distinction  is  between  Examination  and  In- 
spection, already  mentioned: — 

a.  Examination  shall  refer  only  to  the  complete  physical  ex- 

amination of  a  pupil  by  one  or  many  persons,  and  re- 
corded on  an  individual,  cumulative  health  record  card 
for  each  pupil.  The  standard  is  one  such  examination 
a  year,  in  this  country,  less  often  in  Europe. 

b.  Re-examination,  or  re-examined,  shall  refer  to  the  work  done 

by  any  person  who  duplicates  any  part  of  the  physical 
examination  because  of  a  need  for  more  technical  ex- 
amination, because  of  doubt  as  to  the  reliability  of  the 
first  findings,  or  for  the  purpose  of  checking  up  one  or 
more  of  the  first  examiners. 

c.  Inspection  shall  refer,  when  relating  to  pupils,  to  any  partial 

examination,  looking  at,  or  study  of  a  child  or  children 


n4    SCHOOL  HEALTH  ADMINISTRATION 

with   a  view  to   learning   the   condition  of   their  health, 
outside  of  the  two  forms  of  examination  given  above.     A 
pupil  should  be  examined  thoroughly  once  a  year,  perhaps, 
but  he  may  be  inspected  fifty  or  more  times, 
d.  Inspection,    as   a  term,   may  be  used    also   to    refer   to    any 
study  of  school  sanitation,   home  hygiene,  or  any  other 
external  feature. 

a.  Examinations.  Nearly  every  city  that  attempts  com- 
plete routine  examinations  of  pupils  has  provided  an 
individual,  cumulative  health  record  card  for  each  pupil,  and 
this  definition  will  not  exclude  any  city  of  the  twenty-five 
that  actually  gives  examinations.  The  work  of  examina- 
tion is  usually  divided;  and  we  find  all  agents  from  teachers 
to  oculists  making  the  vision  examinations,  and  nurses,  den- 
tists and  doctors  making  the  medical  examinations,  and 
hearing  tests.  Some,  also,  have  physical-training  teachers 
make  certain  measurements  of  height,  weight,  chest  expan- 
sion, and  the  like;  and  have  in  each  school,  or  haul  about, 
platform  scales  with  attached  height  standards.  These  lat- 
ter measurements  are  probably  not  worth  the  effort  taken 
to  get  them.  Doctors  use  other  indexes  in  making  diagnoses, 
and  the  examinations  as  usually  made  with  shoes  and  cloth- 
ing on  are  entirely  valueless.  The  usual  fate  of  such  meas- 
urements, in  the  writer's  experience,  has  been  to  fill  physical 
training  or  medical  inspection  supervisor's  offices  with  waste 
paper.  As  principal  for  several  years,  the  writer  made  such 
measurements  for  an  entire  school,  and  found  just  one  value 
in  them:  they  could  be  used  as  a  means  of  teaching  the 
pupils  the  principles,  ideals,  and  habit  of  correct  carriage 
and  deep  breathing.  The  best  development  of  these  anthro- 
pological measurements  seen  by  the  writer  will  be  found  in 
the  1910  and  1911-12  reports  of  medical  inspection  in 
Dunfermline,  Scotland.  Even  here  they  seem  to  have  little 
pragmatic  value  and  it  is  significant  that  chest  expansion 
measurements,  given  with  doubt  as  to  their  value  in  the 
1910  report,  are  not  mentioned  in  the  last.  Here,  we  can 
only  raise  the  problem. 

It  seems  the  better  and  growing  practice  that  nurses  in- 
stead of  doctors,  teachers,  principals,  or  physical-training 


EFFICIENCY  OF  HEALTH  WORK         115 

teachers  make  the  vision  and  hearing  tests,  where  there  is 
no  school  oculist  for  visual  examination,  or  only  for  re- 
examination  of  actual  cases  as  at  Providence.  The  nurses 
can  learn  to  make  these  examinations  as  easily  as  any  of  the 
other  officials,  and  they  have  the  several  advantages  of  being 
the  ones  to  get  treatments,  glasses,  etc.,  of  having  a  number 
of  schools  to  examine  in,  thus  giving  more  skilled  practice 
and  more  uniformity,  of  being  cheaper  workers  than  phy- 
sicians, of  doing  the  work  without  turning  aside  and  being 
"bothered,"  as  is  often  the  case  with  teachers,  principals  and 
physical-training  teachers.  States  do  well  to  have  teachers 
do  this  work  where  there  are  no  nurses;  but  cities  and  rural 
districts  having  nurses  should,  very  probably,  place  the 
matter  in  their  hands  and  give  them  training  for  doing  it 
well.  Oculists  can  be  employed  for  re-examining  the  cases 
the  nurses  find  and  for  prescribing  glasses,  treatment  or 
operations  for  those  who  need  them. 

Aurists  can  be  attached  to  school  clinics  for  the  hearing 
and  discharging-ear  cases. 

b.  Re-examinations.     The   nature   of   this   process   has, 
possibly,  been  clearly  enough  stated.     It  is  very  little  used. 

c.  Inspections   of  pupils.     These  will  be    explained   in 
detail  in  the  tentative  standard  plan  given  later.     Here  it 
may  be  repeated  that  they  are  either  routine  or  occasional 
inspections  of  all  the  children  in  rooms  or  schools  for  any 
general  affections  of  a  serious  character,  or  for  some  special 
ailment  such  as  pediculosis,  infectious  diseases,  uncleanliness, 
and  the  like. 

Individual  inspections  are  made  of  pupils  referred  to 
nurses  and  doctors  by  teachers,  principals  or  parents;  of 
pupils  returning  from  over  two  or  three  days'  absence  or 
longer,  either  voluntarily  absent,  excluded,  quarantined,  or 
for  any  other  reason;  and  of  pupils  entering  the  school  for 
the  first  time,  after  the  first  two  weeks  or  more  of  school. 
The  September  room-inspection,  or  such  inspection  after 
each  vacation  or  at  the  beginning  of  each  term,  will  catch 
pupils  entering  in  the  first  two  or  three  weeks. 


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117 


n8     SCHOOL  HEALTH  ADMINISTRATION 

THE  TABLE 

Turning,  then,  to  table  VII  we  see  that  only  eight  of  the 
twenty-five  cities  have  complete  examinations;  and  that  all, 
of  course,  have  more  or  less  of  inspection.  A  city  may  have 
only  inspections  by  doctors  and  nurses,  and  have  vision  and 
hearing  examinations  by  teachers.  The  latter  are  only  par- 
tial examinations,  and  are  not  always  recorded  on  individual 
cumulative  health  record  cards  as  described.  Some  do  not 
have  the  complete  examinations,  and  must,  therefore,  be 
classed  simply  as  medical  inspection  systems  in  the  narrow 
sense,  and  yet  have  the  vision  and  hearing  tests  (partial- 
examinations)  by  nurses,  teachers,  doctors,  or  others.  The 
strong  tendency  is,  however,  in  the  direction  of  the  complete 
examination  along  with  the  inspection. 

Only  one  city  seems  to  have  examined  all  children  in  the 
school  system,  including  the  high  school  pupils,  South  Man- 
chester, although  a  few  had  some  inspection  in  the  high 
school.  The  Boston  Board  of  Education  employed  a  special 
physician  (salary,  $1,008)  for  the  high  school  examina- 
tions, but  no  record  was  obtained  of  his  work.  In  Newark 
and  Jersey  City  the  directors  of  the  departments  of  medical 
inspection  examined  a  number  of  pupils  in  the  high  schools. 
The  results  are  not  included  in  this  report  of  cases,  or  exami- 
nations. Summit  began  examining  high  school  pupils  in 
1912-13. 

The  percentage  of  the  enrolled  elementary  pupils  medi- 
cally examined  varies  from  about  42  per  cent  in  Newark  to 
100  per  cent  in  South  Manchester.  The  average  for  the 
eight  cities  (not  including  Syracuse,  where  we  have  only  a 
record  of  work  certificate  examinations,  by  the  Board  of 
Health)  is  about  84  per  cent.  In  Newark,  the  number 
would  have  been  greater  had  more  of  the  inspections  and 
vision  and  hearing  tests  been  made  by  nurses  or  teachers 
instead  of  by  the  doctors.  (There  were  but  eight  nurses 
for  the  entire  city  with  nearly  sixty  thousand  elementary 
pupils.)  The  same  may  be  said  for  Hoboken  in  part,  for 
Rochester,  Jersey  City,  and  Meriden. 

The  average  number  of  pupils  examined  by  each  phy- 


EFFICIENCY  OF  HEALTH  WORK         119 

sician,  with  and  without  the  help  of  the  nurses,  varies  from 
935  in  Newark  to  2,924  in  Hoboken,  with  Jersey  City  not 
far  behind  (2,797).  The  doctors  in  Hoboken,  however, 
were  paid  $100  a  month  instead  of  $30  and  $40  as  in 
Jersey  City  and  Newark.  They  were  required  to  give  three 
instead  of  two  hours  a  day  as  a  rule,  also.  Other  conditions 
being  about  equal,  according  to  time  spent,  they  should  have 
50  per  cent  more  examinations,  and  according  to  pay  about 
three  times  as  many.  The  number  of  inspections  made  in 
Newark,  especially,  is  quite  large,  perhaps  a  reasonable 
number  in  Jersey  City,  while  the  number  is  not  given  in 
Hoboken,  although  the  cases  found  by  such  inspections  are 
given.  Both  Jersey  City  and  Newark  give  also  the  number 
of  room  inspections,  or  "class  inspections."  None  are  given 
for  Hoboken.  Newark  has  given  the  doctors  very  much 
inspection  to  do,  especially  classroom  inspection,  and  so  gets 
fewer  examinations. 

In  Summit,  the  nurse  assisted  the  physician  at  all  ex- 
aminations and  made  350  "examinations"  herself.  The  lat- 
ter may  have  been  only  inspections.  Where  the  nurse  assists 
the  physician  at  the  examinations  there  are  many  advantages 
and  few  disadvantages :  She  learns  a  great  deal  of  the 
science  and  practice  of  medicine,  with  a  good  physician, 
especially  as  related  to  the  care  of  her  school  children;  she 
learns  just  what  ails  each  pupil  and  what  would  probably  be 
the  best  ways  of  handling  the  different  cases ;  she  assists  the 
physician  greatly  by  making  the  vision  and  hearing  examina- 
tions, getting  the  children  ready  for  the  examinations  by 
calling  them  from  their  rooms,  calming  their  fears,  keeping 
them  in  control,  getting  them  washed  if  necessary,  removing 
or  loosening  part  of  the  clothing,  etc. ;  she  frequently  helps 
to  make  all  of  the  records,  reports,  notices,  and  the  like; 
she  gets  the  physician's  advice  immediately  regarding  any 
part  of  the  examination  she  is  making  and  over  which  she 
is  puzzled;  she  frequently  observes,  from  her  own  experi- 
ence, certain  defects  or  ailments  which  the  physician  may 
overlook;  and  last,  but  not  least,  she  learns  to  know  the 


120    SCHOOL  HEALTH  ADMINISTRATION 

abnormal    child   with    respect    to    the    normal    child    as    a 
standard. 

In  Summit,  one  school  has  an  exceptionally  fine  medical 
supervision  room — large,  well-lighted,  even  if  in  a  partial 
basement,  and  fairly  well  equipped  with  tables,  desks,  hot 
and  cold  water,  screens,  a  couch,  medical  cabinet,  etc.  It 
is  probable  that  the  nurse  and  physician  working  together 
as  a  team  in  the  complete  examinations  of  pupils  can  examine 
better  125  pupils  in  the  same  time  it  would  take  them 
separately  to  examine  100  pupils.  No  exact  figures  are  ob- 
tainable on  this  problem.  I  know  of  no  special  disadvan- 
tages of  such  teamwork  examinations.  In  Montclair,  each 
school  has  a  janitress,  as  well  as  a  janitor,  and  these  women 
are  unusually  helpful  in  all  examinations  and  inspections, 
saving  very  much  time  for  all  concerned.  They  even  give 
the  treatments  for  pediculosis. 

NUMBER    OF   EXAMINATIONS 

Only  125  daily  visits  about  an  hour,  on  the  average,  in 
actual  medical  work  with  pupils  (not  counting  travel  to  and 
fro)  were  made  by  the  physician  in  Summit.  How  many  of 
these  were  visits  when  only  inspections  were  made  we  are 
not  told;  we  judge  from  the  report  of  many  calls,  probably 
25,  leaving  100  for  examinations  of  1,034  pupils.  For, 
say,  170  daily  visits  of  two  hours  each  and  with  the  assist- 
ance of  the  nurse,  and  with  not  a  great  many  inspections  to 
make,  we  should  expect  the  physician  to  make  (100  is  to  2 
times  170  that  1,034  is  to  ?)  or  3,515  examinations,  say, 
3,000  annually.  With  a  good  deal  of  the  inspection  of 
referred  cases  to  do,  this  3,000  would  probably  be  the  maxi- 
mum number  annually.  Here,  however,  the  nurse  was  also 
attendance  officer,  throwing  more  inspection  to  the  doctor. 

Jersey  City  physicians,  working,  according  to  the  rules, 
two  hours  a  day  and  making  the  vision  and  hearing  tests, 
and  without  the  continuous  help  of  the  nurse  (6  nurses  to 
12  doctors)  and  with  the  same  average  number  of  individual 
inspections,  besides  936  class-room  inspections,  report  almost 
the  same  average  number,  2,797,  doing  better,  probably,  as 


EFFICIENCY  OF  HEALTH  WORK         121 

to  quantity  than  any  other  city.  We  cannot  judge  as  to  the 
quality  of  these  examinations,  of  course. 

In  Trenton,  the  doctors,  without  much  help  from  the 
nurses,  except  for  vision  testing,  report  an  average  of  1,323 
examinations,  and  1,047  inspections  in  89  visits,  on  the  aver- 
age, of  not  much  over  an  hour  each  in  actual  school  medical 
work.  The  school  year  was  196  days.  Counting  only  170 
daily  visits  again,  we  should  expect  at  this  rate  from  each 
physician  giving  the  same  time  as  now  (89  is  to  170  that 
1,323  is  to  ?),  or  2,250  examinations,  and  almost  a  propor- 
tionate number  of  inspections.  For  twice  the  time,  which 
on  the  average  would  probably  not  exceed  two  hours,  we 
should  have  4,450  examinations.  Then  3,000  would  seem 
to  be  a  minimum  number,  at  least  a  very  reasonable  number, 
especially  since  we  have  deducted  no  days  from  the  89  for 
mere  inspection  visits. 

At  Rochester,  for  which  we  have  the  number  of  daily 
visits  but  do  not  have  the  average  number  of  hours  a  day 
for  each  physician,  our  estimate,  given  in  another  table,  is 
one  hour.  At  any  rate,  an  average  of  170  visits  is  given, 
but  how  many  mere  inspection  visits  we  do  not  know.  The 
highest  number  of  examinations  reported  is  2,334  and  the 
lowest  by  a  regular  examiner  (180  by  a  specialist)  is  484. 
The  median  is  about  1,550.  Since  we  have  the  figures,  this 
is  a  better  figure  perhaps  than  the  average  because  of  the 
wide  variation.  For  twice  the  time  we  should  again  expect 
over  3,000  examinations  as  a  median  performance,  and  with 
nurses  making  the  vision  and  hearing  tests  and  helping  at 
the  examinations  and  making  more  inspections  (only  three 
nurses  for  the  city),  we  should  expect  4,000.  So  3,000 
here  for  two  hours  a  day  seem  not  to  be  unreasonable. 

Meriden  physicians  made  an  average  of  1,207  complete 
examinations  without  a  nurse's  assistance  (only  one  nurse 
for  the  city)  after  the  first  of  November  when  the  system 
got  started.  For  ten  months  the  number  could  probably 
have  been  1,500.  They  averaged  probably  an  hour  each 
day.  For  twice  the  time,  and  with  no  re-examination  of 
defective  vision  cases  reported  by  teachers  (leaving  this  to 


122     SCHOOL  HEALTH  ADMINISTRATION 

nurses)  and  no  measurements,  we  see  that  probably  3,000 
pupils  could  easily  have  been  examined  during  the  school 
year,  and  twice  as  many  inspections  made  by  each  doctor. 

Perhaps  experience  will  show  that  desirable  improve- 
ment in  the  quality  of  examinations  will  force  a  reduction  to 
a  lower  maximum  than  3,000.  Ohio  has  been  discussing  a 
state  law  for  this  maximum  number  for  physicians  and  efforts 
have  been  made  to  make  the  number  2,000.  Careful  ex- 
periments have  not  yet  been  made  which  will  make  possible 
any  dogmatism.  Lack  of  funds  requires  a  large  number  of 
pupils  for  each  examiner,  to  start  with.  And  if  three  thou- 
sand can  be  examined  by  one  man  it  will  be  desirable. 

VISION  AND   HEARING  TESTING  BY  TEACHERS,   NURSES  AND 

OCULIST 

These  tests  were  all  made  by  the  teachers  in  Massachu- 
setts and  Connecticut,  and  to  some  extent  in  Providence.  The 
records  are  unsatisfactory.  In  Massachusetts  the  examina- 
tions are  made  annually.  The  rules  for  Meriden,  Conn., 
were  as  follows: 

"Teachers  shall  make  the  vision  tests  and  the  proper 
records  in  connection  therewith  in  September,  or  whenever 
they  may  enter,  for  all  new  children  above  first  grade;  in 
February  for  all  children  in  first  grade;  and  once  in  three 
years  for  all  children.  Tests  may  be  omitted  in  the  kinder- 
gartens." 

Teachers  reported  all  children  with  vision  20/40  or 
worse,  and  pupils  with  even  better  vision  but  with  evidences 
of  eyestrain,  headaches,  etc.,  to  the  doctors,  and  no  others. 
The  latter  re-examined  the  pupils,  and  had  the  nurse  send 
out  messages.  Had  the  re-examination  been  made  by  a 
school  oculist  and  prescriptions  given  it  would  have  been 
better. 

The  stop  watch  and  whisper  tests  are  chiefly  used  to  test 
hearing.  Groups  of  children  are  often  tested  at  a  time 
in  this  manner.  The  common  test  is  whether  the  pupil  can, 
with  each  ear  and  without  seeing  the  lips,  hear  distinctly 
low  spoken  words  or  sentences  at  a  reasonable  distance.  No 


EFFICIENCY  OF  HEALTH  WORK         123 

attempt  of  which  I  know  has  been  made  to  use  the  audio- 
meter. Probably  nearly  all  cases  are  found  with  little 
trouble  in  the  present  manner.  Efforts  should  be  made, 
however,  to  standardize  and  make  objective  the  meas- 
urement. 

The  number  of  pupils  tested  for  vision  in  proportion  to 
elementary  school  enrollment  varies  from  zero  in  Mt.  Ver- 
non  and  Syracuse  up  to  a  hundred  per  cent  in  four  cities. 
Hoboken,  perhaps,  made  more  tests  than  are  recorded  by 
the  nurse. 

Where  the  nurses  tested  for  vision  or  hearing  or  both, 
we  are  interested  in  the  ayerage  number,  for  such  tests  take 
up  considerable  time.  We  know  the  facts  for  only  one  city, 
without  qualification.  Trenton's  two  nurses  made  on  the 
average  3,245  vision  tests  each.  Their  other  work  seems 
to  be  little  less  than  that  of  other  nurses. 

EXAMINATIONS 

We  have  seen  that  the  number  of  examinations  may  well 
be  nearly  3,000  for  two  hours  a  day,  five  days  a  week,  the 
nurse  making  vision  and  hearing  tests  and  measurements,  if 
possible,  the  nurse  assisting  at  the  examinations,  and  the 
work  lasting  through  the  school  year. 

This  may  be  seen  to  be  a  probably  reasonable  number 
by  beginning  at  the  other  end,  the  number  of  examinations 
in  an  hour.  With  no  other  work,  and  the  nurse  and  doctor 
working  as  a  team,  and  with  simple  records,  at  least  ten 
pupils  can  be  examined  as  a  reasonable  number,  in  an  hour, 
twenty  in  a  two  hour  period. 

Without  many  individual  inspections,  this  would  be  in 
185  school  days,  3,700  pupils  for  each  doctor  with  a  nurse. 
Counting  off  for  all  forms  of  inspection,  but  placing  the 
burden  of  it  upon  the  nurse,  we  see  again  coming  out  the 
estimate  of  a  reasonable  maximum  number,  perhaps,  of 
3,000  pupils. 

In  the  long  run,  it  seems  best  to  give  to  nurses  the  vision 
and  hearing  testing.  How  often  these  should  be  made  is 
doubtful,  probably  not  as  often  as  once  a  year  for  all  pupils, 


i24    SCHOOL  HEALTH  ADMINISTRATION 

as  a  matter  of  routine.  In  Europe,  the  complete  examina- 
tions come  only  three  or  four  times  in  a  course  of  eight 
years.  The  Meriden  intervals  are  recommended  for  con- 
sideration. Probably  every  other  year  would  be  wise. 

In  Newark  and  several  cities,  the  children  with  20/30 
normal  vision  are  recorded  defective  and  referred.  The 
more  universal  and  desirable  practice  is  to  follow  the  Eng- 
lish and  Massachusetts  plan  given,  referring  only  those 
20/40  or  less,  unless  they  have  other  symptoms  of  eyestrain 
or  other  eye  defects. 

The  Massachusetts'  rules  for  hearing,  quite  generally 
followed,  give  25  feet  in  a  still  room  as  the  easily  heard 
"standard  whisper"  (if  there  is  such  a  thing),  35  to  45 
feet  for  a  low  voice,  and  45  to  60  feet  for  a  loud  voice. 
Most  medical  rooms  in  schools,  or  the  places  assigned  to 
doctors  and  nurses  in  old  buildings  are  very  poorly  adapted 
for  such  work.  Halls  are  frequently  used  to  give  the  desired 
space. 

INSPECTIONS  OF  ELEMENTARY  PUPILS 

We  can  hardly  discover  the  number  of  inspections  of 
the  different  kinds.  The  doctor  at  Waterbury  reports  as 
many  as  250  inspections  an  hour.  This  is  by  class-rooms  and 
principally  pediculosis  and  infectious  disease  inspection.  Dr. 
Mercelis  of  Montclair  estimates  50  children  an  hour  as  a 
reasonable  number  to  inspect  by  rooms.  Individual  inspec- 
tions are,  of  course,  scattered  over  days  and  weeks,  and  prob- 
ably take  from  one  to  five  minutes  each.  As  we  glance  down 
the  columns,  we  see  that  Waterbury  and  Syracuse  are  count- 
ing room-inspections  as  individual  inspections.  Newark  and 
Jersey  City  are  the  only  cities  giving  the  number  of  indi- 
vidual and  the  number  of  room-inspections  separately. 
Several  give  only  the  individual  inspections  referred  to  them 
by  nurse  and  teachers.  Room-inspections  should  be  recorded 
by  rooms  rather  than  by  the  number  of  individual  pupils 
in  them. 

Boston  included  a  parochial  group  of  children,  but  the 
average  is  about  7,000  children  inspected  for  each  doctor. 


EFFICIENCY  OF  HEALTH  WORK         125 

How  many  room  inspections  are  in  this  we  could  not  learn. 
It  is  an  average  of  over  40  a  day  for  170  days,  probably 
more  than  any  physician  served. 

Yonkers'  physicians  made  no  examinations  and  averaged 
for  the  two,  7,437  inspections  each.  How  many  different 
children  this  represents  we  do  not  know.  Any  pupil  may 
have  been  inspected  many  times  in  a  year.  There  were  only 
71  school-visits  (one  school,  one  visit),  with  sometimes  two 
or  three  schools  in  a  day.  Unfortunately,  the  number  of 
daily  visits  was  not  kept  separate.  But  even  counting  it  as 
71  school  visits,  the  average  number  inspected  at  each 
school  visit  was  somewhat  over  a  hundred. 

Since  we  obtained  from  the  reports,  the  facts  regarding 
the  number  of  times  different  schools  were  visited  in  Yonkers 
by  the  two   physicians,    and  since   the   Superintendent   has 
characterized  each  one  for  us,  we  give  here  these  data : 
Six  schools  visited  only  once  during  the  year,  mostly  small 
country  schools. 

Four   schools   visited   only   twice   during   the   year,   partly 
small  country  schools. 

Three   schools  visited   only   three   times   during  the  year, 
two  in  rich  districts. 

Two  schools  visited  only  four  times  during  the  year,  one 
rich,  the  other  rural. 

One  school  visited  only  five  times  during  the  year,   aver- 
age, city. 

One  school  visited  only  seven  times  during  the  year,  large 
and  poor. 

One  school  visited  only  eight  times  during  the  year,  large 
and  poor. 

One  school  visited  only  nine  times  during  the  year,  large 
and  poor. 

One  school  visited  only  eleven  times  during  the  year,  large 
and  poor. 

In  sum,   20   schools   visited  only   seventy-one  times   during 
the  year,  by  the  two  physicians. 

The  average  number  of  school-visits  for  the  20  schools 
is  less  than  4  for  each  school,  and  ten  or  half  of  them  were 
visited  less  than  three  times,  in  185  days  of  the  school  year. 
The  city  had  only  one  nurse  to  assist  the  doctors.  The 
enormous  number  of  cases  in  proportion  to  the  number  of 
doctors  and  nurse  (given  in  a  later  table)  shows  a  need, 
probably  greater  than  for  any  city  visited,  of  an  enlarged 


126    SCHOOL  HEALTH  ADMINISTRATION 

force.  (Yet  the  writer  was  told  that  Yonkers  was  a  wealthy 
city  and  needed  little  such  work.)  One  school  with  23  and 
another  with  27  teachers  besides  the  principals  were  visited 
but  three  times  each,  and  another  school  with  25  teachers 
was  visited  but  twice. 

In  Brockton,  the  small  number  of  inspections  by  doctors 
is  due  to  the  fact  that  in  this  city  the  physicians  are  used 
only  for  consultation  over  puzzling  cases,  by  the  nurse.  An 
average  of  436  cases  each  is  thus  recorded.  There  was  but 
one  nurse  for  the  entire  city.  One  of  the  physicians  is  on 
the  Board  of  Education,  and  donates  his  services.  The 
work  here  shows  what  nurses  may  do  alone  if  properly 
supervised.  Oakland,  California,  has  a  large  force  of  nurses 
with  one  full-time  directing  physician ;  and  the  system  seems 
to  work  well.  No  one  is  on  part-time.  Pupils  fail  to  get 
the  same  number  of  skilled  routine  examinations  in  such  a 
system,  but  the  puzzling  cases  may  be  re-inspected  for  the 
nurses;  and  probably  nearly  all  real  ailments  may  be  found. 

The  median  number  of  individual  inspections,  throwing 
out  room-inspections  which  should  be  counted  by  rooms  as 
in  Newark  and  Jersey  City  (rather  than  by  the  number  of 
pupils  in  them),  is  probably  not  far  from  3,000.  With  the 
system  devised  as  given  for  examinations,  this  number  could 
probably  easily  be  raised  to  5,000,  not  counting  room-in- 
spections, of  which  there  would  be  for  each  physician  (3,000 
pupils,  divided  by  40)  75  in  the  routine  September  room- 
inspections. 

In  Jersey  City,  the  average  number  of  rooms  inspected 
for  each  physician  was  78,  and  in  Newark  (counting  an 
average  of  26  physicians),  383,  or  an  average  of  two  or 
three  a  day.  This  large  amount  of  room-inspections  in 
Newark  probably  accounts  for  the  small  number  of  exami- 
nations. The  average  number  of  individual  inspections  is 
also  large,  over  8,000.  Most  of  this  inspection  work  could 
be  placed  in  the  hands  of  nurses  at  about  half  the  salary 
per  hour  with  probably  better  results,  since  the  work  is  rela- 
tively simple  when  once  learned,  and  since  the  nurse  must 
follow  up  the  cases  anyway. 


EFFICIENCY  OF  HEALTH  WORK         127 

The  grades  in  which  most  inspection,  probably  eighty 
per  cent,  is  done  are  the  first  three  or  four.  Most  inspectors 
wisely  emphasize  this  age  period  not  only  because  there  are 
many  more  cases,  but  because  of  the  greater  number  of 
serious  diseases  and  deaths  at  this  age  and  the  desirability 
of  nipping  pathological  tendencies  in  the  bud  if  possible. 

INSPECTIONS    BY   NURSES 

The  number  of  inspections  by  nurses  is  given  in  the  next 
columns  (65  and  66).  They  range  upward  from  practically 
zero,  where  nurses  spend  their  entire  time  following  up 
cases  found  by  physicians.  Several  of  the  cities,  especially 
those  with  board  of  health  control  of  this  work  are  in  or 
very  close  to  this  class.  We  need  not  specify,  because  in  most 
cities  even  nurses  so  restricted  would  probably  find  a  num- 
ber of  cases  without  making  any  inspections  (searches)  for 
them  in  the  schools.  In  the  list  of  ailments  given  in  a  later 
table  the  fact  that  nurses  in  any  city  report  more  cases  than 
are  reported  by  the  doctor  and  possibly  referred  to  them 
would  indicate,  where  she  has  not  met  the  same  case  a 
large  number  of  times,  that  they  were  probably  finding  new 
cases  themselves.  A  great  weakness  in  the  reporting  lies 
here.  It  is  impossible  to  discover  how  many  new  ailments 
were  found  by  both  doctors  and  nurses,  and  how  many  were 
merely  referred  from  the  former  to  the  latter.  The  term 
"case"  should  be  avoided  in  all  reports,  Bailments"  and 
"children"  are  better,  since  a  "case"  may  mean  several  dif- 
ferent ailments. 

The  nature  of  the  report,  or  the  lack  of  a  report,  on 
this  item  leaves  a  blank  record  of  inspections  for  the  nurses 
of  twelve  cities.  The  reporting  for  nurses  is  so  relatively 
new  that  we  should  expect  the  emphasis  to  be  placed  in 
reports  upon  the  work  of  the  physician.  Most  nurses  here 
probably  deserve  much  better  reports  than  they  made  or  re- 
ceived. The  large  average  figures  in  Brockton,  Schenectady 
and  Syracuse  mean  a  large  number  of  class-room  inspections 
where  the  number  of  pupils  rather  than  the  number  of 
rooms  was  recorded.  But  the  record  of  Newark  is  ex- 
traordinary, for  not  only  were  there  an  average  of  20,000 


128     SCHOOL  HEALTH  ADMINISTRATION 

individual  inspections  for  each  of  the  eight  nurses,  but  there 
were  an  average  of  493  class-room  inspections  each,  and  an 
average  of  an  extra  750  inspections  for  uncleanliness  each. 
This,  with  an  average  of  1,118  home  visits  would  seem  to 
place  the  amount  of  work  done  by  each  Newark  nurse  far 
ahead  of  all  others  reporting.  This  is  very  probably  due  to 
an  excellent  administration  of  their  work  as  well  as  to 
adequate  reports  and  faithful  performance  of  duty.  How- 
ever, it  is  difficult  to  make  accurate  comparisons. 

For  Trenton  we  give  the  number  of  inspections  by  a  new, 
and  by  an  experienced  nurse,  the  latter  making  2,477  m~ 
spections  to  the  other's  993.  The  more  experienced  the 
nurse  in  this  work  the  more  of  the  service  of  inspections  can 
be  given  her. 

Were  we  to  divide  the  average  of  41,205  pupils  in- 
spected by  each  nurse  in  Schenectady  by  an  average  sized 
class,  say  40,  we  should  have  a  figure  nearer  the  general 
tendency.  Were  we  to  allow  for  5,000  individual  inspec- 
tions we  should  still  have  900  room  inspections  each.  At  a 
half  hour  each,  these  would  amount  to  90  school  days  of  5 
hours  each.  In  Brockton,  the  17,365  inspections  (called 
"examinations"  as  they  are  in  most  cities)  were  as  follows: 
throat  inspections,  7,589;  re-inspected  (general),  605;  in- 
spected (general)  next  term,  7,971;  re-inspections  at  office, 
600.  As  before  related,  1,309  were  also  re-inspected  by  the 
doctors. 

The  median  number  of  individual  inspections  for  each 
nurse,  W/orking  35  to  44  hours  a  week,  is  probably  near 
4,000.  How  many  class-room  inspections  can  be  added  to 
this  depends  upon  the  amount  of  home  visiting  and  the 
character  of  the  supervision.  First-class  supervision  means 
in  general  first-class  work.  Lack  of,  or  poor,  supervision 
generally  means  work  of  uneven  quality  and  a  low  general 
average. 

The  range  of  inspections  is  from  946  in  Mt.  Vernon,  all 
probably  actual  ailments  referred  by  doctors  and  teachers, 
up  to  the  large  numbers  named. 


EFFICIENCY  OF  HEALTH  WORK         129 

What  would  be  a  good  standard  for  a  nurse  with  the 
plan  mentioned  would  probably  not  be  far  from : 

4,000  individual  inspections  Newark  nurse  20,000 

200  class-room  inspections  Newark  nurse  493 

1,000  home  visits ,.  .Newark  nurse  1,118 

500  treatments,  by  the  nurse Newark  nurse  5,623 

300  taken  to  dispensary  or  physician Newark  nurse  108 

3,000  examinations,  assisting  the  physician.  .  .Newark  nurse  ? 

The  examinations  wkh  the  physician  would  take  prob- 
ably one-fourth  of  the  time.  After  school,  before  school 
and  on  Saturday  mornings  the  home  visits  and  part  of  the 
dispensary  visits  could  be  made.  In  the  remaining  three 
hours  of  each  day,  the  inspections  and  treatments  could  be 
given.  On  the  right,  in  the  statement  above,  are  given  the 
average  figures  for  each  nurse  in  Newark.  They  are  far 
ahead  in  all  but  dispensary  visits  and  assisting  at  examina- 
tions. If  possible,  the  standard  of  number  of  treatments 
by  the  Newark  nurses  should  be  equaled.  Treatments  by 
the  nurse  should,  however,  be  separated  from  treatments  by 
others  outside  of  the  schools.  Nothing  less  than  this  and 
school  clinics  will  effectually  root  out  or  keep  down  a  very 
large  number  of  bad  filth  and  infectious  ailments.  Newark 
has  gone  far  ahead  of  all  cities  in  the  treatment  of  these 
minor  ailments  of  the  poor,  ignorant  and  needy,  at  least  so 
far  as  records  go.  Without  such  treatment,  the  expensive 
system  quite  largely  fails  to  function,  even  though,  as  in 
Newark,  a  great  many  treatments  were  made  by  outside 
agencies,  such  as  hospital  dispensaries,  private  physicians, 
dentists,  oculists  and  parents. 

PERCENTAGE    OF    ELEMENTARY    SCHOOL    POPULATION 

DEFECTIVE 

It  is  again  very  difficult  to  learn  the  percentage  of  pupils 
defective,  because  cases  and  not  children  in  many  instances 
are  reported.  The  approximate  numbers  so  far  as  could  be 
learned  by  much  patient  delving  and  inquiry  are  given  in 
column  69.  The  percentages  in  the  next  column  show  the 
proportion  of  the  elementary  school  population  affected. 
The  cases  below  22  per  cent  are  not  representative  and 


130    SCHOOL  HEALTH  ADMINISTRATION 

simply  mean  that  the  cases  were  not  found,  the  inspections 
being  limited  almost  entirely  to  infectious  ailments  in  certain 
cities,  as  can  be  seen  from  the  table  of  ailments  found.  The 
six  cities  below  50  per  cent  could  all  be  explained  in  this 
manner.  Hoboken  alone,  probably,  has  an  unmerited  low 
standing.  The  facts  could  not  be  learned  from  the  reports. 
The  eleven  cities  with  no  percentages  would  probably  show 
a  similar  range  as  the  fourteen  given.  The  highest  per- 
centage given  is  66  per  cent  and  this  is  doubtful,  because  of 
the  confusion  as  to  cases,  ailments,  and  children.  Newark's 
report  is  definite  on  this;  and  60  per  cent  seems  to  be  near 
the  truth. 

But  most  ailments  are  teeth  defects,  percentages  ranging 
up  to  90  frequently  being  given  for  the  number  of  children 
so  affected.  Many  children  are  in  good  health  with  but  this 
one  exception.  Leaving  out  such  children  with  the  great 
people's  disease,  we  have  a  series  of  ratios  (column  70)  in 
the  more  representative  cities  hovering  around  30  to  35 
per  cent.  We  should  probably  be  quite  safe  in  prophesying 
that  one  out  of  three  of  all  the  pupils  in  a  school  system  are 
each  year  at  some  time  seriously  ailing  or  defective,  not 
counting  defective  teeth  and  about  twice  this  percentage  if 
teeth  are  counted.  Roughly,  a  third  have  no  serious  ail- 
ments, a  third  have  only  teeth  defects,  and  a  third  have  teeth 
defects  and  some  other  ailments  or  defects.  We  dare  take 
neither  the  space  nor  the  time  here  to  compare  in  detail 
these  results  with  those  of  other  investigators.  The  New 
York  percentages  for  1911,  with  230,243  pupils  examined, 
are  quite  similar,  only  larger  in  defectiveness: 

New  York 
My  General  Estimate.  Results,  1911. 

With  no  ailments 33  per  cent.         27  per  cent. 

With  only  defective  teeth 33  per  cent.         39  per  cent. 

With  D.  T.  and  other  ailments.      34  per  cent.         34  per  cent. 

The  likeness  is  striking,  and  shows  the  conditions  of  child 
health  in  the  various  cities  to  be  probably  much  more  nearly 
similar  than  are  the  doctors'  reports.  The  general  per- 
centage for  defectiveness  in  the  whole  elementary  school  pop- 


EFFICIENCY  OF  HEALTH  WORK         131 

ulation,  taken  together,  and  greater  in  the  lower  grades,  is 
about  67  per  cent;  for  New  York  City  it  is  74  per  cent. 

If  this  standard  is  fairly  accurate,  dividing  the  ele- 
mentary school  children  roughly  into  three  equal  groups 
(good,  fair,  bad)  we  can  use  it  as  a  measuring  rod  for  de- 
termining both  the  health  problem  of  medical  supervision 
and  how  cities  are  meeting  it. 

We  can  say,  for  example,  that  systems  which  find  less 
than  forty  per  cent  of  the  pupils  with  defective  teeth,  prob- 
ably are  not  examining  carefully  for  decayed  teeth,  reach 
only  a  part  of  the  school  population,  or  have  had  a  wonder- 
ful crusade  of  dentistry. 

A  number  of  the  cities  named  fall  far  below  these 
standards.  Eleven  cities  do  not  give  the  facts  from  which 
to  judge. 

Likewise  we  can  say  that  cities  finding  enormous  per- 
centages of  defective  teeth,  for  example,  probably  have  their 
standards  for  defectiveness  too  low,  so,  too  many  are 
counted;  or  that  the  city  is  just  beginning  the  work  (if  this 
really  makes  much  difference),  or  that  here  we  have  a  fac- 
tory town  with  much  poverty,  ignorance  and  immigrants. 

Whether  the  standards  stand  the  test  of  time  or  not,  the 
value  is  in  the  beginning  of  such  standardization  of  school 
health  procedure.  We  hope  the  percentages  of  defective- 
ness  may  be  greatly  lowered.  Later  chapters  derive  tenta- 
tive standards  for  each  ailment,  and  group  of  ailments. 

CURES  AND  IMPROVEMENTS  OF  AILMENTS 

The  function  of  medical  inspection  (or  of  medical  su- 
pervision) is  not  only  to  find,  but  to  promote  the  cure  and 
prevention,  of  pupils'  ailments.  The  emphasis  should  be 
strongly  upon  the  side  of  cure  and  prevention.  Prevention 
is  so  much  a  social  and  economic,  as  well  as  a  school  prob- 
lem, that  we  may  be  pardoned  for  a  while  in  concentrating 
upon  cures,  until  our  studies  lead  us  back  into  those  funda- 
mental methods  of  prevention  such  as  educational,  economic, 
and  eugenic  reform.  To  get  cures  there  must  be  treatments. 
We  have  recorded  all  the  treatments  by  nurses  alone,  and  by 


132     SCHOOL  HEALTH  ADMINISTRATION 

other  agencies,  in  separate  columns  (cols.  71  and  72). 
They  are  not  accurate,  because  the  two  forms  of  treatment 
are  frequently  confused  or  reported  together,  or  the  records 
are  poor  or  misleading.  That  nurses  should  succeed  so  well 
in  getting  all  these  thousands  of  treatments  in  one  of  these 
early  years  of  a  great  movement,  is  occasion  for  great  praise 
and  satisfaction.  We  are  sure  that  many  more  in  the  blank 
spaces  would  make  fair  or  good  showings  had  we  the  facts. 

But  how  many  defective  children,  or  what  percentage  of 
the  ailments  received  treatment?  The  data  hardly  permit 
a  guess.  Newark  records  more  than  twice  as  many  treat- 
ments as  children  ailing,  and  three-fifths  as  many  cures  as 
children  ailing  ("cases").  The  number  of  cures  is  larger 
than  the  number  of  children  defective;  and  this  is  quite  nor- 
mal for  the  average  number  of  defects  to  a  child  is  about 
two.  We  must  find  the  number  of  new  ailments  rather 
than  the  number  of  children  defective  in  this  problem,  and 
relate  it  to  the  number  of  ailments  treated  and  cured. 

The  number  of  ailments  found  is  given  in  another 
column  (82).  After  it  comes  the  number  referred,  showing 
that  some  cities  record  many  minor  ailments  which  they  do 
not  set  out  to  get  cured.  It  were  better  that  they  remain 
unrecorded,  it  seems.  Until  cities  list  for  each  ailment  treat- 
ments and  cures,  this  problem  of  percentage  of  cases  treated 
will  remain  unsolved.  Later  we  shall  show  that  favus  cases 
in  Dunfermline  were  treated  in  the  school  clinic  in  one  year 
on  the  average  94  times;  so  we  have  complicating  features. 
Newark's  data  would  give  the  facts  except  that  the  exami- 
nations covered  less  than  half  of  the  elementary  school 
population  and  the  inspections  covered  all.  Judging  only 
from  the  total  number  of  ailments  or  children  ailing  found 
by  the  examinations  we  should  say  that  60  per  cent  were 
cured.  But  there  were  cases  (ailments)  found  also  by  the 
doctors  in  inspecting  children  not  examined,  those  who  had 
been  examined  earlier  in  whom  new  ailments  had  arisen, 
and  also  new  cases  (ailments)  by  the  nurses  not  found  by 
the  physicians  and  referred  to  them.  When  we  have  the 
sum  of  all  these  new  cases  (ailments)  and  then  the  sum  of 


EFFICIENCY  OF  HEALTH  WORK         133 

all  cures,  we  can  arrive  at  general  conclusions  as  to  efficiency. 
In  some  way  we  must  know  the  total  number  of  children 
afflicted  and  the  number  of  ailments  these  children  had  and 
what  was  done  with  them. 

What  the  form  of  reports  should  be  in  this  field  we  shall 
attempt  to  work  out  in  a  final  chapter. 

The  efficiency  of  the  nurses  is  not  adequately  shown  in 
these  figures  of  treatments,  cures  and  improvements.  Ex- 
perience in  Philadelphia  and  elsewhere  has  shown  over  and 
over  again  that  parents  respond  to  only  about  five  or  six 
per  cent  of  the  notices  of  children's  ailments  without  the 
assistance  of  the  nurse.  With  an  adequate  force  of  nurses 
and  good  backing,  they  will  probably  raise  this  percentage 
up  to  fifty  per  cent  or  more.  If  doctors  were  more  con- 
servative about  referring  ailments  this  percentage  would 
be  raised  still  higher,  quite  legitimately  and  easily,  perhaps 
up  to  eighty  or  more  per  cent.  Better  concentrate  all 
energies  on  the  worst  cases,  than  to  disgust  parents  and 
family  physicians  with  notices  of  trivial  ailments.  "The 
doctor  sent  us  home  a  notice  that  my  little  sister  was  too 
tall  for  her  age,"  said  one  young  lady  to  me.  "What  does 
he  expect  us  to  do  to  her?" 


See  the  comparison  of  results  of  work  of  doctors  and  nurses  for 
different  ailments  and  for  different  social  grades  of  population  given  in 
the  pamphlet  entitled  "Medical  Inspection  of  Public  Schools,  Philadel- 
phia, 1913,"  printed  by  the  Board  of  Education  for  the  Fourth  Inter- 
national Congress  on  School  Hygiene.  The  charts  show  that  parents 
seem  to  be  responding  better  to  doctors  than  formerly,  but  that  the 
nurse  is  indispensable. 

Further  efficiency  tables  will  be  found  in  Chapter  Nine. 


CHAPTER    SIX 

THE  AILMENTS  OF  PUBLIC  SCHOOL  CHILDREN 

A.    PHYSICAL  DEFECTS 

THE  AILMENTS  OF  PUBLIC  SCHOOL  CHILDREN  IN  25  CITIES 
The  Classification  of  School  Ailments 

The  first  and  most  difficult  problem  connected  with  a 
comparative  study  of  the  work  done  by  doctors  and  nurses 
as  reported  in  these  twenty-five  cities  has  been  that  of  mak- 
ing a  simple,  working  classification  of  the  ailments  of  school 
children.  Several  hundred  different  names  for  the  various 
ailments  occurred  in  the  various  reports;  many  names  for 
the  same  ailment  were  used;  and  no  one  classification  or 
system  of  nomenclature  seemed  satisfactory.  The  word 
"ailment"  here  is  used  to  cover  all  defects  and  diseases,  and 
seems  preferable  to  the  term  disorders  used  by  Dr.  Hoag, 
although  the  latter  serves  the  purpose. 

There  are  a  number  of  classifications  of  human  ailments 
but  their  bases  are  all  pretty  largely  that  of  their  death- 
dealing  character  and  the  parts  of  the  body  affected.  There 
is,  for  example,  the  International  Classification  of  Diseases 
and  Injuries,  the  Bellevue  Classification  (Bellevue  Hospital, 
New  York  City),  the  classification  used  by  the  U.  S.  Mor- 
tality Statistics,  and  the  various  classifications  used  by  local 
and  state  boards  of  health.  They  are  really  classifications 
of  the  direct  causes  of  death.  One  of  the  first  distinctions 
here  is  the  fact  that  the  ailments  most  affecting  school  chil- 
dren and  school  work  are  quite  largely  not  death-dealing. 
The  proportion  of  ailments  from  which  school  children  die 
is  a  very  small  share  of  the  total  found.  As  can  be  seen  at 
the  end  of  the  table,  columns  214  to  217  and  210  to  211, 
the  deaths  of  children  of  school  age  in  each  city  are  very 

134 


AILMENTS  OF  SCHOOL  CHILDREN       135 

few  in  comparison  with  the  number  of  cases  of  disease  and 
these  of  ailments  which  occur  comparatively  infrequently. 
Moreover,  the  recorded  school  ailments  are  not  all  occurring 
in  the  age  population,  5-19  inclusive.  The  classification  of 
ailments  here  must  be  a  school  classification. 

The  problem  then  became  a  choice  of  names,  or  terms, 
and  of  division,  or  classification,  in  the  logical  sense.  The 
classifications  finally  devised  were  one  based  upon  the  loca- 
tion of  the  various  ailments  such  as  is  used  by  the  Boston 
Board  of  Health,  and  a  simpler  classification,  on  a  more 
pragmatic,  educational  basis.  These  two  classifications  were 
duplicated  and  sent  out  to  a  few  nurses,  medical  examiners 
and  supervisors  of  medical  supervision  with  the  result 
that  the  location-basis  classification  was  rejected.  There 
were  too  many  divisions;  and  after  such  a  classification  is 
completed,  there  always  appear  ailments  which  must  go  into 
a  miscellaneous  group  almost  as  large  in  some  cases  as  the 
well-classified  portion.  We  have  a  miscellaneous  group  in 
our  tables  largely  because  of  ailments  recorded  only  as 
"miscellaneous"  in  the  reports. 

The  classification  finally  adopted  and  here  offered  for 
criticism  is  as  follows: 

I.  Communicable  Ailments. 

A.  Parasitic  and  Minor. 
B.  Infectious  Diseases. 

II.  Non-Communicable  Ailments. 

A.  Physical  Defects. 

B.  Common  Ailments. 

The  work  of  placing  the  many  terms  used  for  the  vari- 
ous ailments  under  a  few  (54)  rubrics  was  done  with  the 
help  of  the  following  texts : 

a.  Holt's  "Diseases  of  Childhood  and  Infancy,"   Ap- 
pletons. 

b.  McComb's  "Diseases  of  Children  for  Nurses,"  W. 
B.  Saunders  Co. 

c.  Hoxie's  "Practice  of  Medicine  for  Nurses,"  W.  B. 
Saunders  Co. 


136    SCHOOL  HEALTH  ADMINISTRATION 

d.  Ditman's   "Home  Hygiene  and  Prevention  of  Dis- 
ease," Duffield  &  Co. 

e.  Cornell's  "Health  and  Medical  Inspection  of  School 
Children,"  F.  A.  Davis  Co. 

f.  Hoag's  "The  Health  Index  of  Children,"  Whitaker 
&  Ray-Wiggin  Co. 

g.  Medical  Dictionaries. 

Some  of  the  practical  considerations  which  have  in- 
fluenced this  selection  of  terms  have  been  the  following: 

a.  The  names  of  ailments  actually  used  most  commonly 
by  school  doctors  and  nurses. 

b.  The  names  which  would  be  most  easily  understood 
by  the  parents  and  citizens  to  whom  reports  are  supposed 
to  be  made. 

c.  Grouping  the  ailments  according  to  the  divisions  of 
the    work.      Nurses    have    almost    exclusive    control    over 
parasitic  and  minor  infectious  ailments,  for  example. 

d.  Emphasizing  important  and  often  neglected  ailments 
and  divisions  of  ailments  by  position.     This  accounts   for 
placing  the   word   "dental"   before    "teeth,"    for   example. 
Important  divisions  and  ailments  are  placed  high  in  the  list 
when  possible. 

e.  The  number  of  ailments  which  would  be  an  optimum 
number  upon  which  to  report,  taking  into  consideration  the 
many  practical  exigencies. 

For  certain  of  these  reasons  the  division  of  non-com- 
municable ailments  is  placed  first.  These  ailments  are  prob- 
ably most  important  for  school  life,  especially  physical  de- 
fects. Diseases  which  occur  very  infrequently  or  have  little 
effect  upon  school  life  are  omitted,  blank  places  being  left 
after  each  group  on  our  report  for  writing  in  these,  if  found. 
(See  final  chapter.)  We  recommend  that  an  N.  E.  A. 
committee  be  appointed  to  further  condense  and  standardize 
the  classification. 

The  reader  should  examine  the  complete  classification 
given  in  the  last  chapter. 

All  classifications  are  compromises  and  are  to  be  judged 
by  the  service  they  render.  The  many  faults  in  this  clas- 


AILMENTS  OF  SCHOOL  CHILDREN       137 

sification  are  probably  obvious,  but  it  serves  our  present  pur- 
pose of  displaying  in  convenient  form  the  ailments  found, 
and  may  be  of  value  in  bringing  about  a  more  serviceable 
one  for  the  use  of  schools.  At  present  there  is  practically 
no  genuine  and  satisfactory  classification  in  use  by  any 
schools. 

ANALYSIS   OF   TABLE  VIII 

One  of  the  first  tables  made  by  the  author  was  an  at- 
tempt to  show  the  number  of  cases  found  by  doctors  and  by 
nurses  and  the  number  of  ailments  treated,  improved  and 
cured.  Such  a  table,  while  offering  the  possibility  for  needed 
data,  was  very  cumbrous  and  was  conspicuous  for  its  vacant 
spaces,  the  data  not  being  given  by  enough  cities  to  count 
for  much.  In  the  table  as  here  offered,  there  are  three 
columns  each  for  only  six  physical  defects;  the  ailments 
found  by  the  physicians,  by  the  nurses,  and  the  number 
treated,  cured,  or  found  treated  or  cured.  For  the  most 
part  the  ailments  found  by  the  physicians  are  referred  to 
the  nurses,  especially  where  parents  do  not  respond  within  a 
given  time  (and,  to  repeat,  only  about  five  or  six  per  cent 
of  parents  do  respond  to  physicians'  notices  without  the 
nurses'  visits)  so  the  sum  of  the  doctors'  and  nurses'  cases 
would  not  be  the  true  total  of  ailments.  Every  ailment,  too,  is 
not  a  new  ailment.  In  certain  cities,  and  for  certain  inspectors 
and  nurses  within  cities,  every  time  a  child  is  seen  for  a 
given  ailment  we  get  a  record  for  another  "case,"  ailment. 
This  helps  to  account  for  some  of  the  large  sums  and,  pre- 
sumably, very  bad  morbidity  found  in  certain  cities.  Where 
we  find  a  record  of  very  many  more  cases  of  an  ailment 
found  by  nurses  (See  adenoids  in  Cambridge,  New  Bedford, 
Brockton,  Winchester)  than  by  physicians  we  may  be  sure 
that  here  the  sum  given  by  the  nurse  represents  nearly  all 
the  ailments.  These  difficulties  with  double  reporting  seem 
also  to  point  to  the  nurse  as  the  one  to  make  the  only  and 
complete  reports  of  medical  supervision.  The  record  shows 
in  general  the  total  number  of  cases  found  by  doctors,  re- 
ferred to  the  nurses,  and  "seen,"  treated,  procured  treat- 
ment for,  or  found  treated,  by  later  inspections  by  teachers 


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1 40    SCHOOL  HEALTH  ADMINISTRATION 

or  nurses.  The  nurse's  column  shows,  then,  for  the  most 
part  the  cases  which  the  nurses  themselves  treated  or  tried 
to  get  treated  and  cured  through  the  homes  or  other 
agencies.  There  are  many  excuses,  of  course,  for  the  poor 
showing  which  many  cities  make  on  this  chart,  through  the 
absence  of  better  reporting.  For  a  board  of  health  with 
long  experience  in  the  health  field,  and  with  a  system  of 
medical  inspection  organized  for  several  years,  there  is, 
however,  hardly  any  good  excuse.  For  five  of  the  cities,  the 
writer  made  the  summaries  of  the  doctors'  and  nurses'  re- 
ports for  the  year  studied.  (Norwood,  Montclair,  Water- 
bury,  Yonkers  and  New  Bedford.)  For  several  others, 
partial  summaries  were  made,  as  for  the  nurses  of  Trenton. 
This  partly  accounts  for  the  greater  detail  of  the  records  for 
these  cities.  Most  of  these  cities  have  since  printed  sum- 
maries of  this  work  and  it  has  been  interesting  and  instruc- 
tive to  get  from  these  what  such  a  report  may  mean,  and 
how  much  it  may  vary  from  the  real  work,  and  the  monthly 
and  weekly  records.  The  protracted  and  tedious  labor  of 
making  such  summaries  for  a  year,  especially  where  there 
were  weekly  reports  from  a  number  of  doctors  and  nurses, 
gave  some  valuable  insight  into  what  good  reporting 
should  be. 

Some  cities,  like  Jersey  City  and  some  of  the  board  of 
health  cities,  reported  only,  or  practically  only,  the  excluded 
cases,  children  so  afflicted  that  they  were  sent  out  of  school. 
Such  cases  are,  of  course,  but  a  small  percentage  of  the 
actual  number,  and  such  reports  are  of  little  value  educa- 
tionally. The  efficiency  of  medical  inspection  cannot  be 
measured  or  recorded  by  such  meager  data.  As  they  stand, 
the  records  require  interpretation  city  by  city  and  almost 
item  by  item,  so  many  deductions  of  scientific  exactitude 
cannot  be  drawn  from  them.  It  will  be  necessary  later  to 
take  good  records  of  several  cities  and  make  a  special  study 
of  them. 

Another  thing  which  must  always  be  kept  in  mind  in 
looking  over  such  reports  is  that  many  of  the  ailments  listed 
are  only  "suspected"  ailments.  This  is  especially  true  of 


AILMENTS  OF  SCHOOL  CHILDREN       141 

infectious  diseases,  adenoids  and  any  other  ailments  which 
are  difficult  of  diagnosis.  The  children  are  referred  to 
family  physicians,  clinics  and  dispensaries  for  more  careful 
diagnosis  and  treatment.  This  lack  of  final  responsibility 
for  an  ailment  sometimes  makes  school  medical  workers 
careless.  The  writer  has  seen  many  children  recorded  as 
having  ailments,  adenoids  or  enlarged  tonsils,  for  example, 
where,  from  his  own  study  of  medicine,  and  experience  in 
schools,  hospitals  and  dispensaries,  there  were  no  such  ail- 
ments— the  enlargement  being  quite  normal,  at  least  not 
pathological  enough  to  require  attention  or  treatment.  Such 
cases  are  so  frequently  reported  "negative"  by  family  phy- 
sicians as  to  disgust  the  parents  and  make  the  best  results 
hard  to  obtain.  Exclusions,  too,  are  in  most  cities  far  more 
frequent  than  necessary.  Every  city  should  have  such  su- 
pervision of  this  work  as  will  adequately  review  the  inspec- 
tions, examinations,  exclusions,  etc.,  and  hold  physicians 
and  nurses  as  strictly  responsible  as  the  nature  of  the  work 
will  permit.  Nurses  seem  more  careful  than  doctors,  since 
they  must  follow-up  the  cases. 

A.    PHYSICAL  DEFECTS 

i.  Adenoids.  Some  cities  report  only  "Obstructed 
Breathing"  for  this  defect,  because  physicians  find  it  desir- 
able to  report  the  symptoms  without  making  a  manual  ex- 
ploration which  frequently  hurts  and  frightens  the  children. 
The  medical  phases  of  this  work  are  so  well  treated  by 
Cornell  in  his  text  on  "Medical  Inspection,"  referred  to 
before,  and  in  other  texts,  that  only  some  of  the  administra- 
tive problems  will  be  discussed,  for  the  fifty-four  ailments, 
in  this  place.  Of  the  12,652  adenoid  cases  reported  by 
physicians  and  the  9,311  found  or  seen  to  by  nurses,  cer- 
tainly many  more  than  the  1,993  given  were  treated  or 
found  cured  on  re-inspection.  However,  some  cities  make 
the  mistake  of  taking  the  teachers'  reports  as  to  cures.  No 
ailment  should  be  counted  "improved"  or  "cured"  which 
is  not  found  so  by  competent  re-inspection }  or  checking-up- 
inspection,  by  the  doctor  or  nurse.  Such  obvious  cases  as 
the  wearing  of  glasses  after  vision  has  been  reported  de- 


142     SCHOOL  HEALTH  ADMINISTRATION 

fective,  even,  should  be  handled  in  the  same  way.  The 
glasses  may  not  fit.  This,  in  general,  is  an  administrative 
fact  purchased  very  dearly  in  experience  in  a  number  of 
progressive  cities. 

There  were  also  more  cases  of  adenoids  and  nasal  ob- 
struction found  than  are  here  reported.  Several  cities  have 
no  records  of  this  important  school  ailment.  Meriden  prob- 
ably found  many  cases  but  for  some  unknown  reason  they 
were  not  given  in  the  report. 

Our  interpretation  of  the  Summit  report  is  that  there 
were  38  cases  in  all  found,  but  no  report  was  made  of  those 
operated  on,  or  treated.  The  same  is  true  for  Norwood: 
1 9  cases  found,  no  record  of  cures,  although  the  nurse  did 
take  a  number  of  children  to  the  free  clinics  of  Boston  for 
operations.  For  Winchester,  no  cases  are  reported  by  the 
physician  and  80  are  reported  as  found  and  62  as  cured  by 
operations,  by  the  nurse.  The  report  here  is  in  this  form : 
"Operated  upon  for  tonsils  and  adenoids.  .  .  .62."  We  can- 
not be  sure  that  all  were  operated  on  for  both  adenoids  and 
tonsils  though  this  method  is  quite  general,  since  the  two 
ailments  are  very  closely  associated.  For  reporting,  how- 
ever, the  two  should  be  separated,  since  it  is  only  a  matter 
of  convenience  that  both  operations  take  place  at  once.  The 
report  would  be  better  in  this  form  using  the  terminology 
of  the  report,  "Mouth  breathers,"  80;  operations,  62  (?)  ; 
negative,  — ;  not  treated,  — .  Enlarged  tonsils,  138  ;  opera- 
tions, 62  (  ?)  ;  negative,  — ;  not  treated,  — . 

Although  we  have  only  about  six  or  seven  scientific 
studies  of  the  relation  of  school  defects  to  school  progress,* 
and  consequently  cannot  assert  any  more  than  that  adenoids 
and  nasal  obstructions  have  very  serious  effects  upon  health 
and  school  progress,  it  seems  clear  that  those  cities  which 
have  failed  to  keep  record  of  the  number  of  cases  found, 
and  what  was  done  in  the  way  of  getting  them  cured,  stand 

*See  the  new,  rewritten  edition  of  "Medical  Inspection  of  Schools" 
by  Gulick  and  Ayres  of  the  Russell  Sage  Foundation,  Chapter  IX;  also 
Wallin's  study  of  Oral  Orthogenics  in  the  Cleveland  schools  in  Dental 
Cosmos  for  April  and  May,  1912. 


AILMENTS  OF  SCHOOL  CHILDREN       143 

in  efficiency  far  below  cities  which  make  such  efforts.  Prac- 
tically the  only  cities  emphasizing  the  reporting  of  cure  and 
treatment  are  Newark  and  the  nursing  division  of  Boston. 

Some  of  the  chief  weaknesses  in  the  reporting  of  this 
defect  seem  to  be  as  follows: 

a.  Many  cases  are  undoubtedly  not  "cases"  at  all,  but 
fillers  for  statistical  columns,  "to  frighten  citizens  into  pro- 
viding a  sufficient  corps  of  doctors  and  nurses."     The  phy- 
sician at  Summit  makes  a  good  distinction  between  cases  that 
are  slight  and  those  that  are  really  serious  and  demand  im- 
mediate attention,  as  shown  for  three  defects  as  follows: 

No.  Cases               No.  Cases  Percentage 

Found.  Referred  to  M.D.  Referred. 

Adenoids    34                           34  IOO 

Enlarged  Tonsils 116                           39  25 

Defective   Teeth 552                         155  28 

Defective    Vision 194                          85  43 

Here  it  is  evident  that  only  such  cases  of  adenoids  as 
were  really  serious  were  recorded  and  all  were  reported. 
Why  minor  cases  were  not  recorded  as  is  the  case  of  the 
other  three  defects  named  is  not  told. 

If  such  distinctions  are  made  in  all  cases,  the  placing  of 
minor,  unreferrable  cases  on  the  individual  record  cards  may 
prove  of  some  slight  value;  but  as  a  general  principle  of 
reporting  in  this  field,  experience  in  a  number  of  cities  seems 
to  show  that  only  such  cases  as  need  treatment  and  cure, 
that  are  really  serious  and  demand  attention  by  parents  and 
family  physicians,  should  be  recorded  and  reported.  This 
would  reduce  the  Summit  cases  to  those  of  the  second 
column,  and  this  proportion  of  reduction  would  probably 
apply  to  each  city. 

b.  Many  of  these  cases  are  "re-inspections,"  instead  of 
new  cases.    At  the  time  of  some  inspection  of  the  child,  or 
at  the  time  of  the  physical  examination  in  the  few  cities  that 
have  examinations,  a  pupil  is  found,  for  example,  with  ade- 
noids.   This  is  one  new  case.    But  the  pupil  does  not  obtain 
treatment,  say,  and  is  referred  to  the  school  doctor  again, 
one  or  more  times.     These  re-inspections,  or  better,  "old- 


144    SCHOOL  HEALTH  ADMINISTRATION 

cases,"  are  frequently  counted  as  if  they  were  each  a  differ- 
ent child  with  this  defect,  otherwise,  on  the  poor  report 
forms  supplied,  the  physician  would  get  no  credit  for  his 
work. 

Good  reporting  must  show  the  number  of  children  with 
the  defect  as  "new  cases";  and  all  inspections  to  see  if  a 
child  has  procured  treatment,  is  keeping  up  treatment,  or 
is  progressing  well  after  an  operation  or  other  form  of 
treatment  must  be  recorded  and  reported  as  "old  cases" 
inspected.  See  forms  in  last  chapter. 

c.  Negative  cases  are  not  deducted  from  the  total  num- 
ber of  suspected  cases.    For  example,  a  child  is  diagnosed  as 
having  adenoids.     No  careful  manual  examination  is  made 
or  the  adenoids  are  not  very  large  or  perhaps  only  tem- 
porarily congested.    The  physician  cannot  say  for  sure  that 
this  is  a  case  for  medical  or  operative  treatment,  but  reports 
it  for  the  family  physician  to  pass  upon.     The  family  phy- 
sician examines  the  child  and  calls  it  negative,  or  no  case. 
Unless  a  very  skilled  specialist  in  nose  and  throat  ailments 
is  the  school  physician,   as   is  very  seldom  the  case,  later 
reports  should  deduct  this  case  from  the  total.     I  know  of 
no  city  that  does  this,  although  the  Montclair  reports  make 
it  a  possibility. 

d.  The  nurses  do  not  show  how  many  cases  have  been 
referred  to  them  by  the  school  doctors  and  how  many  they 
have  themselves  found.     Thus    in    Boston,    for    example, 
where  the  physicians  are  under  the  Board  of  Health  and  the 
nurses  are  not,  we  do  not  know  how  many  of  the  2,472  cases 
reported  by  nurses  have  already  been  found  by  the  phy- 
sicians and  referred  to  them,  so  we  cannot  tell  how  many 
cases  were  found  in  the  city,  or  how  many  pupils  suffered 
from  adenoids.    We  suspect  that  the  number  is  far  less  than 
the  sum  of  the  doctors'  and  the  nurses'  cases. 

In  the  case  of  Brockton,  we  know  how  many  cases  were 
found  by  the  nurse,  since  the  doctors  are  used  only  for  con- 
sultation and  consequently  have  no  cases  to  report,  all  being 
found  by  the  nurse.  The  nurse,  however,  fails  to  state 
the  number  of  children  who  had  adenoids,  although  we  sus- 


AILMENTS  OF  SCHOOL  CHILDREN       145 

pect  from  the  report  that  it  is  almost  as  large  as  the  number 
of  "cases." 

Reports  must  distinguish  cases  merely  handed  on  by  the 
physician  from  those  found  by  the  nurse,  and  must  distin- 
guish between  pupils  and  cases,  or  re-inspections. 

e.  Treatments   are    frequently  not   recorded;   many   re- 
corded on  the  teachers'  or  pupils'  statement  without  an  in- 
spection by  nurse  or  physician  are  really  not  treatments  at 
all.     A  pupil  reports  treatment  when  he  hasn't  had  one,  to 
avoid  trouble.     Furthermore,  a  distinction  should  be  made 
in  the  kinds  of  treatment  obtained,  operative  or  medical. 
A  spray  or  gargle  which  has  no  beneficial  effect  is  often  used 
and  is  called  a  "cure"  when  adenoids  are  still  there  after  its 
use  as  bad  as  ever. 

Reports  should  show  that  a  real  cure  or  improvement 
has  or  has  not  been  effected.  Only  an  inspection  will  estab- 
lish this. 

f.  Another  troublesome   matter,    influencing   reports,    is 
the  fact  that  adenoids  "come  back."     The  famous  English 
Board  of  Education    (London)    reports  by  Sir  Geo.  New- 
man, M.  D.,  consider  this.     The  1911  report  shows  (page 
50)  that  many  children  may  be  operated  on  three  or  more 
times  and  the  bad  symptoms  still  remain.     Even  after  an 
operation  which  may  well  be  called  a   treatment   a   child 
should  not  be  called  cured  unless  the  bad  symptoms :  mouth- 
breathing,  snoring  respiration,  nasal  deformities,  etc.,  cease. 
In  the  case  of  adenoids,   this  result  frequently  cannot  be 
obtained  without  widening  the  child's  nasal  passages  at  the 
time  and  after  the  operation,  and  without  breathing  exer- 
cises directed  by  the  regular  or  physical  training  teacher. 
The  latter  has  been  tried  and  found  valuable  in  Montclair, 
N.  J.,  by  the  physical  training  teachers. 

After  all  these  strictures  what  have  we?  How  many 
pupils  in  these  cities  suffered  from  actual,  severe  cases  of 
adenoids  or  other  nasal  obstruction  which  needed  real  treat- 
ment, medical  or  operative;  how  many  got  such  treatment; 
and  how  many  were  cured  of  their  ailment  or  were  only 
improved?  No  one  in  the  world  can  answer  with  accuracy, 


146    SCHOOL  HEALTH  ADMINISTRATION 

and  hardly  approximately.  We  must  remember,  too,  that 
many  severe  cases  missed  attention  in  a  number  of  cities 
because  the  children  were  not  examined  and  because  not  all 
were  even  inspected  for  this  defect. 

The  daily  work  of  doctors  and  nurses  cannot  now  be 
reviewed;  and  the  number  of  mere  estimates  necessary  to 
a  complete  summary  for  the  twenty-five  cities  is  probably  so 
great  that  the  results  will  not  carry  conviction.  The  inspec- 
tion in  most  cities  has  necessarily  covered  only  part  of  the 
elementary  school  population,  so  the  figures  would  be  much 
reduced  by  the  various  considerations  given  above,  and 
would  be  raised  if  we  were  making  the  estimates  for  the 
number  of  ailments  in  the  entire  elementary  school  popula- 
tion. Tentative,  empirical  estimates  seem  to  indicate  that 
the  number  of  cases  set  down  as  the  sum  totals  for  doctors 
and  nurses  is  not  far  from  the  number  of  new  cases,  or 
pupils  affected,  to  be  found  by  both  officials  in  the  total 
elementary  school  population  of  413,393  pupils,  counting 
all  as  new  cases  found  by  the  doctors  and  all  as  new  cases 
found  by  the  nurses  and  not  referred  to  them  by  the  doctors. 
This  would  make  the  number  of  children  having  serious 
cases  of  adenoids  and  nasal  obstructions  about  five  per  cent 
of  the  number  of  elementary  school  pupils.  The  figures 
are  only  two  per  cent  for  Summit,  the  same  in  Winchester, 
and  12  per  cent  in  West  Orange;  but  of  the  last  195  only 
65  were  considered  serious  enough  to  refer  to  the  parents 
and  family  physicians  for  possible  treatment,  making  only 
about  four  per  cent. 

Wherever  we  get  the  actual  number  of  these  cases  that 
are  really  serious  enough  to  be  referred  for  treatment  the 
percentage  does  not  rise  above  that  for  the  total  of  nurses' 
and  doctors'  cases  for  the  twenty-five  cities,  five  per  cent. 
This  is  about  half  the  number,  or  percentage,  usually  given 
as  the  number  of  cases.  About  ten  per  cent  of  all  children 
examined  are  usually  reported  as  having  adenoids  or  other 
nasal  obstruction.*  In  Milwaukee  for  the  same  year, 


*See   1913   edition  of  "Medical  Inspection  of  Schools,"  by  Gulick 
and  Ayres,  page  40. 


AILMENTS  OF  SCHOOL  CHILDREN       147 

1910-1911,  19,616  pupils  were  examined,  of  whom  only 
2,493  were  recommended  for  treatment;  the  total  number 
of  physical  defects  found  were  18,299,  of  which  11,380 
(over  half)  were  defective  teeth,  and  1,049  adenoids  and 
nasal  obstruction.  If  no  cases  were  counted  both  adenoids 
and  "defective  nasal  breathing,"  and  if  all  pupils  with  these 
ailments  were  referred  for  treatment,  which  seems  very 
unlikely  from  the  above  figures,  the  percentage  of  cases  of 
this  defect  is  only  about  five.  It  is  interesting  to  note  here 
also  that  there  were  on  the  average  6.2  defects  for  each 
child. 

2.    ANEMIA 

For  summary  purposes  this  ailment  may  as  well  have 
been  placed  with  malnutrition  and  debility,  perhaps.  It  is 
given  separate  record  because  of  the  large  number  of  sep- 
arate records  given  it  in  the  reports.  The  sum  of  cases 
found  by  doctors  and  nurses  is  4,539,  or  less  than  one  per 
cent  of  the  total  number  of  elementary  children  in  the  cities. 
Boston  has  a  combined  number  of  2,832  or  over  two  per 
cent  of  the  school  population  but  here  quite  evidently  all 
the  doctors'  cases  were  passed  on  to  the  nurses  who  counted 
them  again,  and  found  1,128  new  cases  themselves,  unless 
some  of  the  latter  were  duplications,  from  meeting  an 
anemic  child  more  than  once.  The  number  counted  cured 
of  this  ailment  was  so  small  that  the  figures  given  were  not 
put  down. 

In  the  cities  where  there  were  open-air  schools  (S.  Man- 
chester, Montclair,  Schenectady,  Cambridge,  Providence, 
and  Newark)  it  is  important  and  surprising  to  notice  that 
this  ailment  is  one  most  frequently  given  as  the  cause  of 
admittance,  not  tuberculosis.  The  children  are  anemic  and 
run  down,  probably  suffering  from  malnutrition,  and  need 
rest,  food,  and  recuperation.  The  number  of  tubercular 
children  of  whom  we  hear  so  much  are  conspicuous  by  their 
absence  from  these  reports  (columns  167  to  172  of  the 
table)  only  81  cases  being  found  by  doctors  that  are  not 
marked  merely  suspects,  and  only  223  suspected  and  actual 


148     SCHOOL  HEALTH  ADMINISTRATION 

cases  together.  The  number  of  cases  is  not  great  enough 
to  cause  alarm;  the  important  thing  is  to  find  those  pupils 
who  will  most  surely  become  consumptives  in  early  adult 
life,  and  give  them  special  health  education,  diet,  outdoor 
life,  and  treatment. 

Probably  one  per  cent  of  the  pupils  are  anemic. 

3.    DEAFNESS,    HEARING   DEFECTS 

For  this  ailment,  too,  the  returns  are  very  variable.  In 
Massachusetts  and  Connecticut  the  hearing  and  vision  of 
pupils  are  tested  by  the  teachers.  There  are  no  very  definite 
standards  of  examination  followed  in  this  work;  and  the 
great  number  of  teachers  and  other  persons  engaged  in  it, 
all  with  little  or  no  supervision,  makes  for  little  accuracy 
in  results.  Where  the  tests  are  made  by  teachers,  we  fre- 
quently found  that  the  teachers  had  got  around  the  law 
of  1906  by  detailing  one  of  their  number  in  each  building, 
or  a  teacher  on  each  floor,  to  make  all  the  tests.  A  substitute 
is  called  into  the  teacher's  room  who  does  this  work  for 
herself  and  the  other  teachers,  and  thus  a  certain  amount 
of  school  interruption  is  dispensed  with,  and  a  degree  of 
uniformity  is  reached.  In  several  cities  many  of  the  prin- 
cipals make  the  tests.  This  feature  and  the  fact  that  in 
other  places  the  nurses  make  these  tests  for  the  entire  school 
system  without  any  need  of  a  substitute  and  with  a  great  deal 
better  opportunity  for  skilled  work  and  uniform  standards, 
have  furnished  the  suggestion  for  the  tentative  standard 
plan  found  in  the  last  chapter  that  only  nurses  should  do 
this  work  in  all  cities.  The  reports  of  specialists  in  these 
fields  to  the  legislature  of  Massachusetts  before  the  law  was 
passed,  to  the  effect  that  teachers  could  make  such  tests  even 
better  than  regular  medical  practitioners,  would  be  even 
stronger  when  said  of  the  nurses.*  It  would  be  distinctly 
uneconomical  to  employ  relatively  high  salaried  physicians 
to  do  any  work  that  can  just  as  well  be  done  by  nurses  who, 

*See  1913  edition  of  "Medical  Inspection  of  Schools,"  pages  179 
and  44  to  53,  by  Gulick  and  Ayres. 


AILMENTS  OF  SCHOOL  CHILDREN       149 

hour  for  hour,  receive  only  about  one-third  to  one-half  as 
much  remuneration. 

The  tests  are  chiefly  the  stop-watch  and  whisper  tests, 
and  common-sense  is  about  the  only  standard.  Children  in 
outdoor  life  and  in  the  school  room  should  at  normal  dis- 
tances be  able  to  hear  easily  distinct  speech  lowly  spoken; 
consequently  whisper  or  low-spoken  sentences  will  probably 
always  be  an  important  part  of  good  testing.  The  Massa- 
chusetts tests  as  given  in  detail  in  the  book  just  mentioned 
are  the  models  which  most  of  the  other  cities  follow.  Treat- 
ment is  rarely  recorded,  largely  because  the  defect  is  often 
permanent,  and  is  generally  treated,  if  treated  at  all,  indi- 
rectly by  treatment  or  removal  of  adenoids,  defective  teeth, 
enlarged  tonsils,  chronic  catarrh,  colds,  discharging  ear 
(otitis  media),  and  the  like. 

The  teacher's  treatment  of  the  child  should,  of  course, 
be  modified  by  reports  of  defective  hearing;  but  the  writer 
has  found  that  this  matter  has  been  much  neglected  for 
frequently,  and  this  is  true  of  all  ailments  of  school  chil- 
dren, not  enough  attention  has  been  given  to  notifying  the 
teachers  of  the  ailments  and  making  it  necessary  and  pos- 
sible for  them  to  readjust  themselves  to  the  children  in  the 
light  of  this  new  knowledge  of  them.  Some  cities  send  a 
record  of  every  ailment  immediately  to  the  teachers  of 
the  individual  children,  and  some,  like  New  Bedford,  Mass., 
have  small  room-filing-cases  on  each  teacher's  desk  for  this 
purpose.  It  seems  a  good  plan  for  the  child  to  take  such 
a  room  card  with  him  to  the  nurse  or  physician  for  each 
examination  or  inspection,  carrying  it  in  a  fold  of  clean, 
blank  paper  for  its  protection,  and  having  the  physician  or 
nurse  record  their  findings  on  the  card  and  write  any  special 
report  for  the  teacher  on  the  clean  slip  of  paper.  The 
records  of  nurse  and  physician  could  be  distinguished  by  the 
nurse  using,  say,  red  ink  in  her  fountain  pen  and  the  doctor, 
black.  I  know  of  no  city  following  this  plan;  but  it  is 
these  details  which  help  most  to  bring  about  efficiency. 

The  percentage  of  defective  hearing  cases  to  total  ele- 
mentary or  entire  school  population  can  hardly  be  made,  for 


150    SCHOOL  HEALTH  ADMINISTRATION 

reasons  given  in  connection  with  adenoids.  In  Summit, 
there  were  12  cases  among  1,034  elementary  school  children, 
reported  as  follows : 

"Ears — The  number  of  pupils  with  defective  hearing  or 
discharging  ears  was  twelve  (about  i  per  cent).  This  is 
about  one-half  the  number  found  last  year,  and  is  due 
largely  to  the  correction  of  defects  by  medical  treatment, 
or  removal  of  adenoids  and  enlarged  tonsils  since  the  last 
examination  was  made." 

How  many  cases  had  defective  hearing  only,  we  are 
not  told.  If  there  were  eight  serious  cases,  that  were  not 
merely  temporarily  defective  because  of  bad  colds,  which 
is  probably  a  big  estimate,  the  percentage  would  be  .7  of 
one  per  cent. 

This  caution  is  true  for  practically  all  nose,  throat  and 
ear  ailments,  the  proportion  of  cases  found  being  greater 
in  the  winter  months  when  the  children  have  bad  colds.  A 
room  inspection  of  children  in  September  will  give  a  certain 
number  of  cases  of  adenoids,  tonsils,  defective  hearing,  dis- 
charging ear,  and  the  like;  and  if  the  same  children  are 
again  inspected  in  December  or  February  a  great  many  more 
cases  will  be  found.  Physicians  and  nurses  who  are  most 
conscientious  and  intelligent  in  this  work  take  care  to  distin- 
guish between  temporary  and  severe  or  chronic  ailments. 

The  percentages  for  some  of  the  cities  are  as  follows 
(for  elementary  children  only)  :  Norwood,  .9;  Winchester, 
i;  West  Orange,  .3;  Montclair,  (16  cases),  .5;  Meriden, 
.4;  Brockton,  1.8;  Hoboken,  .7;  Trenton,  .5;  Newark,  .6: 
in  all  an  average  of  about  .7.  As  these  are  cities  where  the 
tests  were  made  for  most  of  the  elementary  school  children, 
we  can  see  that  the  actual  percentage  is  well  under  one  per 
cent.  Taking  the  figures  as  they  stand,  the  percentage  for 
New  Bedford  (414  cases)  is  over  3;  for  Rochester  (628 
cases),  2.6.  These  need  not  be  taken  seriously.  The  nurse 
at  New  Bedford  for  the  year  was  new  to  the  work,  and  had 
not  a  developed  standard  and  the  cases  were  first  found  by 
the  teachers;  while  the  work  at  Rochester  was  done  by 
school  physicians  who  evidently  set  the  standard  too  low. 


AILMENTS  OF  SCHOOL   CHILDREN       151 

Although  most  investigations  of  this  defect  place  it  at  one 
per  cent  of  the  children  examined  in  the  elementary  school, 
the  writer  is  convinced  that  half  that  amount,  .5,  would  be  a 
truer  statement  of  the  actual  number  of  cases  where  the 
defect  was  a  genuine  handicap  to  the  children;  and  that  it 
would  be  better,  as  said,  to  report  only  these,  and  make 
adequate  provisions  for  their  special  consideration  and 
treatment. 

4.    DENTAL,   OR  TEETH   DEFECTS 

The  reason  for  using  the  term  "dental"  instead  of 
uteeth"  is  the  same  as  that  for  using  the  words  "eyesight," 
"enlarged"  before  tonsils,  and  "glands"  before  enlarged: 
for  various  administrative  and  other  reasons  these  terms 
must  be  emphasized  by  position.  Some  of  the  most  im- 
portant school  ailments  can  be  given  a  forward  place  in  the 
classification  in  this  way,  and  physicians  and  nurses  can 
easily  learn  to  use  this  form  of  nomenclature  when  it  be- 
comes standard.  An  alphabetical  order  makes  some  terms, 
otherwise  not  so  desirable,  good  for  this  purpose. 

Defects  of  the  teeth  which  require  dental  treatment 
and  advice  are  among  the  most  important  of  the  ailments 
of  childhood,  both  because  of  their  frequency  and  because 
of  their  indirect  effect  on  general  health.  Defective  teeth 
might  with  truth  be  called  "the  great  American  disease"  as 
the  figures  in  these  columns  show.  In  any  general  sum- 
mary of  the  ailments  of  childhood  and  youth,  such  as  shown 
in  the  next  table,  defective  teeth  will  probably  always  stand 
at  the  top  of  the  list  in  the  number  of  children  affected. 
The  figures  given  in  these  columns  (58,  59,  60)  represent 
for  the  most  part  the  number  of  children  affected,  not  the 
number  of  teeth  decayed,  or  needing  dental  care.  This  is 
especially  true  of  the  doctors'  cases.  One  case  of  defective 
teeth  may  give  the  nurse  several  inspections  for  toothache, 
"gum-boils,"  etc.;  but  on  the  whole  each  child  with  defec- 
tive teeth  has  been  counted  but  once. 

The  chief  administrative  and  statistical  problems  to  be 
considered  in  this  rapid  review  of  the  table  are : 

a.  Ratio  of  number  of  children  with  defective  teeth  to 


152     SCHOOL  HEALTH  ADMINISTRATION 

number    of    elementary    school    children,    and    number    of 
pupils  examined. 

b.  Percentage  of  children  with  teeth  seriously  defective. 

c.  Relative  attention  to  teeth  by  Boards  of  Health  and 
Boards  of  Education. 

d.  Percentage  of  cases  treated. 

e.  Effect  of  treatment  upon  school  progress. 
All,  of  course,  cannot  now  be  answered. 

The  following  quotation  from  the  report  of  the  medical 
examiner,  Dr.  W.  J.  Lamson,  of  Summit,  in  his  June  30 
report,  1911,  will  serve  as  an  illuminating  preface  to  the 
examination  of  these  teeth  columns: 

"Teeth — Particular  attention  has  been  paid  to  the  teeth, 
as  their  condition  is  of  so  much  importance  to  the  young 
child.  It  is  deplorable  to  find  that  over  50  per  cent  of  the 
school  children  have  an  unsound  condition  of  the  oral  cavity 
— either  decayed  or  unclean  teeth.  A  pupil,  for  instance, 
with  decayed  teeth,  is  constantly  absorbing  poisons  into  the 
system.  The  glands  of  the  neck  try  to  protect  the  rest  of 
the  body,  become  enlarged,  and  frequently  later  become 
tubercular.  The  child  is  anemic,  listless  and  unhealthy. 
Parents  neglect  to  have  such  teeth  filled  or  extracted,  because 
the  child  is  young.  And  yet  it  is  of  great  importance  to- 
the  child  to  have  clean  and  sound  teeth.  One  hundred  and 
fifty-five  cases  were  urgently  in  need  of  dental  care,  and 
their  parents  were  notified.  Each  pupil  was  told  the  im- 
portance of  oral  hygiene  and  urged  to  use  a  tooth  brush 
daily." 

The  nurse  in  her  report,  which  largely  omits  statistics 
and  gives  only  the  personal  side  of  the  equation,  also  em- 
phasizes the  importance  of  caring  for  defective  teeth  because 
of  their  bad  effect  upon  digestion,  and  strongly  urges  a 
dental  clinic. 

Here  we  find  552  children  with  defective  teeth,  as  de- 
scribed, among  1,034  pupils  examined,  or  53  per  cent.  But 
only  155  cases  were  "urgently  in  need  of  dental  care"  and 
referred  to  parents  for  dentistry.  This  number  is  only  15 
per  cent  of  the  total  number  of  children  examined,  and  but 


AILMENTS  OF  SCHOOL  CHILDREN      153 

28  per  cent  of  the  number  of  children  with  defective  teeth. 

The  ratio  of  defective  teeth  to  elementary  school  en- 
rollment is  552  to  i, 088,  or  about  51  per  cent.  For  seri- 
ously defective  teeth  it  is  only  14  per  cent. 

How  many  temporary  teeth  are  here  recorded;  why 
unref erred  cases  were  recorded;  why  parents  of  all  children 
with  teeth  defective  enough  to  record  were  not  informed; 
how  many  of  the  155  received  treatment  that  could  be 
called  cures,  we  are  not  told. 

One  other  fact,  only,  is  given:  that  "in  school  No.  i 
where  the  higher  grades  (seventh  and  eighth)  are  located, 
27  per  cent  of  the  scholars  had  defective  teeth,  as  compared 
with  63  per  cent  for  the  rest  of  the  schools." 

This  fact  is  true  for  all  cities,  that  all  ailments  decrease 
with  the  age  of  the  pupils  from  about  the  third  or  fourth 
school  years,  except  defective  vision.  In  Summit,  the 
ratios  of  defects  in  the  higher  grades  and  in  the  lower  grades 
were  as  follows:  Adenoids,  i  per  cent  and  4  per  cent;  en- 
larged glands,  6.5  per  cent  and  n  per  cent;  defective 
vision,  21  per  cent  and  18  per  cent;  enlarged  tonsils,  9  per 
cent  and  12  per  cent;  vermin,  3  per  cent  and  nearly  17  per 
cent  (16.6).  What  Ayres,  in  his  book  on  "Laggards  in 
Our  Schools,"  has  shown  to  be  true  for  his  New  York  cases, 
is  found  true  wherever  studied.  Most  or  all  of  childhood's 
ailments  decrease  with  age  except  defective  vision,  which 
increases.  Not  a  very  great  tribute  to  the  hygiene  of  the 
schools  rooms  and  teachers  of  America !  For  myopia  is  a 
school  ailment. 

DEFECTIVE    TEETH    IN    SOUTH    MANCHESTER 

Here  a  "special  physical  examination  was  made  of  all 
pupils  in  the  school  system"  in  October,  1910.  Of  1,725 
pupils  examined,  538  were  reported  as  having  defective 
teeth,  a  percentage  of  31.  We  should  expect  a  smaller 
percentage  where  high  school  pupils  are  included  in  the 
examination. 

OTHER    CITIES 

Counting  the  number  given  by  the  nurse  for  Norwood 


154    SCHOOL  HEALTH  ADMINISTRATION 

(984)  we  have  a  percentage  of  62,  or  almost  two-thirds  of 
the  elementary  school  population,  according  to  the  stand- 
ards of  the  nurse  and  doctor.  Here  record  was  kept  of 
112  children  who  received  dental  treatment,  about  n  per 
cent  of  those  reported  as  needing  it. 

In  Winchester,  an  excellent  system  of  co-operation  with 
the  dental  association  has  been  worked  out,  but  the  nurse's 
report  does  not  show  it  for  the  year  put  into  this  study. 
717  children  were  examined  by  dentists  with  the  aid  of  the 
nurse;  and  84  of  these  were  taken  to  the  clinic  and  were 
treated  at  the  small  charge  of  25  cents  each.  The  1910-11 
report  is  better  in  this  respect.  The  school  dentists  exam- 
ined the  teeth  of  2,153  children  and  1,665  cases  were  found 
defective,  or  about  77  per  cent  of  the  children.  To  the 
parents  of  1,544  of  these  1,665  children  dental  notices 
were  sent,  about  7 1  per  cent  of  the  number  examined.  The 
number  who  received  treatment  is  not  given,  although  83 
children  received  reduced  rates  at  the  clinic,  or  a  little  over 
5  per  cent  of  the  referred  cases  (1,544).  Little  can  be 
told  from  these  facts.  It  is  probable  that  dentists  count 
too  many  very  minor  cases.  The  1912  report  states  that 
in  previous  years  "from  90  to  95  per  cent  of  the  pupils 
examined  were  reported  as  needing  dental  attention." 

West  Orange  and  Montclair  quite  evidently  overlooked 
teeth  almost  entirely.  Meriden  physicians  and  dentists 
found  1,648  children  with  defective  teeth  among  3,621 
pupils  examined.  Of  these,  167  cases,  or  10  per  cent, 
obtained  treatment  (7  primary  teeth  and  160  permanent). 
Here  we  have  (where  "only  the  most  obvious  cases  were 
noted,"  according  to  Superintendent  Kelly,  1910-11  Report, 
page  33),  45  per  cent  of  the  pupils  examined  with  defec- 
tive teeth.  The  report  goes  on,  "But  more  startling  still 
is  the  indifference  of  many  parents  and  their  sympathizers." 
He  urges  dental  clinics  which  would  be  patronized  very 
generally,  he  thinks.  A  part  of  this  indifference  is  due  to 
the  fact  that  the  work  was  so  new  at  this  time,  really  get- 
ting started  little  earlier  than  the  second  month  of  the 
school  year. 


AILMENTS  OF  SCHOOL   CHILDREN       155 

Some  of  the  other  percentages  are  as  follows: 

Newton,  2207  cases,  on  elementary  school  population,    5,987 — 37  per  cent 
Yonkers,  3063  cases,  on  elementary  school  population,  12,562 — 24  per  cent 

There  were  very  probably  many  more  cases  than  this 
latter  number,  because  two  physicians  could  not  cover  well 
the  entire  city.  Part  of  the  nurse's  cases  may  be  new 
cases  not  found  by  the  physicians.  Of  these  cases  1,235 
cases  are  reported  as  cured,  or  about  40  per  cent.  The 
author's  own  careful  summary  of  the  reports  of  the  phy- 
sicians, however,  showed  only  1,631  cases  of  defective 
teeth;  and  only  12  cases  of  defective  teeth  were  found 
in  the  nurse's  reports;  and  yet  the  printed  summary  made 
by  the  nurse  shows  2,474  cases  and  662  treated.  There 
is  nothing  in  the  monthly  reports  to  back  up  these  figures. 

In  Trenton,  with  a  very  much  larger  elementary  school 
population,  and  8  physicians  working  five  days  a  week  each 
instead  of  two,  as  at  Yonkers* — in  Trenton,  with  713 
school  visits,  or  an  average  of  89  each,  the  number  of  cases 
of  defective  teeth  found  is  only  3,276,  or  31  per  cent  of 
the  10,587  children  examined.  Here  the  principals  also 
report  results,  although  some  neglected  it.  Of  2,289  cases 
reported  by  them,  only  633  (less  than  6  per  cent  of  the 
number  examined)  are  recorded  as  being  referred  for  treat- 
ment, or  only  28  per  cent.  Of  these  only  13  are  reported 
as  cured,  76  improved  and  292  not  treated.  These  figures 
simply  show  that  the  work  of  seeing  what  was  accom- 
plished was  not  done,  and  emphasizes  the  experience  bought 
dearly  in  New  York  and  elsewhere  that  no  cures,  treat- 
ments, improvements,  or  anything  of  the  kind  should  be 
reported  without  an  inspection  by  the  physician  or  nurse 
to  ascertain  that  fact. 

Notice  of  the  excellent  dental  clinic  in  the  City  Hall  at 
Trenton  will  be  made  in  a  later  chapter. 

*Where  only  71  school  visits  were  made  by  the  two  doctors  in  the 
year,  about  35  each,  6  schools  visited  but  once,  4  schools  but  twice,  3 
but  thrice,  2  four  times,  I  five  times,  and  i  seven,  i  eight,  i  nine  and 
I  eleven  times,  not  one  of  the  20  schools  being  visited  by  the  physicians 
more  than  n  times,  and  the  average  less  than  four  visits  each. 


156    SCHOOL  HEALTH  ADMINISTRATION 


In  Waterbury  the  Dental  Association  made  a  careful 
investigation  of  the  condition  of  the  children's  teeth  and 
have  worked  out  probably  the  best  statistical  reports  of 
teeth  defects  found  in  any  of  the  cities.  This  report  may 
be  found  in  the  1910-11  report  of  the  superintendent  of 
schools  and  in  later  reports,  and  a  complete  summary  for 
seven  schools  is  here  appended.  In  the  annual  report  a 
separate  report  on  the  same  form  is  given  for  each  school. 
"The  only  cost  to  the  Board  of  Education  has  been  the 
furnishing  of  a  dental  chair  and  some  other  necessary  ap- 
paratus, the  whole  expense  amounting  to  less  than  two 
hundred  and  fifty  dollars  ($250)." 

SUMMARY  OF  DENTAL  EXAMINATION  OF  SCHOOL 
CHILDREN  IN  SEVEN  SCHOOLS  BY  THE  WATERBURY 
DENTAL  ASSOCIATION  IN  1910. 


Grades.  2        3 

Condition  of  the 
mouth — 

Good    256     389 

Bad    215     352 

Condition  of  the 
gums — 

Good    392     583 

Bad    83     178 

Use  of  the  tooth 
brush — 

Yes    101     238 

No    362     522 

Teeth  filled— 

Yes    58       64 

No   426    694 

Mai-occlusion — 

Yes  154  404 

No  327  456 

No.  of  teeth 
decayed  ..  .2,721  4,583  3,631  3,105  2,008  1,699  M75 


279 
440 


545 
172 


239 
36i 


93 
601 


324 
373 


351 
265 


445 
1 60 


255 
357 

92 
523 


329 
286 


236 
218 


324 
129 


240 

221 
IOO 

345 

201 
251 


233 

III 


278 
64 


191 
152 

74 
267 

170 
173 


137 
76 


178 
33 


130 

83 

57 
158 

102 
105 


126 
58 


150 

34 


152 
42 


95 
87 


Totals. 


2,007    54% 


2,905 
583 


1,646 

2,100 

589 
3,145 

1,679 
2,058 


77% 
23% 


44% 
56% 

16% 
84% 

45% 
55% 


993  19,912    or 


Total  No. 
pupils  . 


5-3  each 

•474     758     693     618     455     342     214     182     3,736 
Here,  then,  we  have  a  table  made   by  dentists  them- 
selves, and  from  it  we  can  make  the  following  more  or  less 
pertinent  observations : 


AILMENTS  OF  SCHOOL   CHILDREN      157 

a.  The  number  of  children  with  bad  dental  conditions 
is  astonishingly  large.    Among  3,736  children  in  all  grades 
from  the  second  to  the  ninth,  inclusive,  there  were  found 
19,912  decayed  teeth,  an  average  of  about  5    1/3  to  each 
child.     Unfortunately,  we  are  not  told  how  many  children 
had  defective  teeth  among  the  3,736.     The  horizontal  col- 
umn marked  "condition  of  the  mouth  bad"  does  not  repre- 
sent this  number.     Here  we  see  that  1,735  children,  or  46 
per  cent  of  those  examined,   had  a  bad  condition  of  the 
gums  or  mal-occlusion,  but  some  were  counted  good  who 
had  decayed  teeth. 

b.  The  figures  are  not  accurate.    The  dentists  evidently 
tried  to  place  all  the  children  in  one  of  two  classes  for  the 
first  five  items.     If  they  had  done  so  the  sum  of  the  two 
numbers  for  each  item  would  be  the  number  of  children 
for  the  grade,  given  at  the  bottom.     However,  there  is  a 
fair  degree  of  correspondence,  the  difference  usually  being 
slight. 

c.  The  number  of  cases  of  defects  is  greatest  in  the 
third  grade,  with  a  few  less  in  the  second  grade,  almost  as 
many  or  more  in  the  fourth  grade,  and  a  gradual  decrease 
to  the  ninth. 

For  bad  condition  of  the  mouth  we  have  the  following 
percentages  of  children  defective: 

Grades.             23456789  Totals. 
No.  pupils 

examined   ...474     758     693     618     455     342     214     182  3,736 

No.  defective..  .215     352     440     265     218     in       76      58  1,735 
Per  cent. 

defective    ...  45       46      63       43       48       32       35       3*      46 

Counting  all  children  who  have  decayed  teeth  or  other 
bad  condition  of  the  oral  cavity,  we  may  conclude  that 
probably  not  far  from  66  per  cent  of  our  elementary  school 
children  are  so  affected,  especially  in  the  first  years  of  med- 
ical inspection. 

5.    ENLARGED  TONSILS 

This  ailment  is  quite  closely  associated  with  adenoids. 
We  should  expect  to  find  more  cases  of  it  than  of  adenoids, 


158     SCHOOL  HEALTH  ADMINISTRATION 

because,  as  the  superintendent  at  South  Manchester  puts 
it,  "when  the  examiner  found  a  well  defined  case  of  en- 
larged tonsils  he  did  not  take  the  time  to  make  an  accurate 
diagnosis  for  adenoids,  for  it  is  the  custom  of  all  surgeons 
who  operate  for  tonsils  to  remove  all  adenoid  tissue"  (1911 
Report,  page  20).  Enlarged  tonsils  are  easily  seen,  while 
adenoids  very  rarely  can  be  seen.*  This  fact  should  help 
to  make  our  findings  for  enlarged  tonsils  more  satisfactory 
than  those  for  adenoids. 

Let  us  turn  our  attention  first,  again  to  the  actual  and 
proportionate  numbers  of  this  ailment  among  the  children 
here  represented.  In  Summit,  "there  were  116  cases. 
.'  .  .  Of  these  only  39  were  so  much  enlarged  as  to 
form  a  serious  obstruction  to'  breathing,  and  the  pupils 
advised  to  have  them  removed.  This  was  done  in  many 
cases."  (Report,  page  22.)  Here  is  a  percentage  of  the 
number  examined  (1,034)  of  11.2  for  all  cases  and  3.7 
for  the  serious  ones.  No  mention  is  made  by  either  doctor 
or  nurse  of  following-up  pupils  and  parents  to  see  that,  or 
if,  they  procured  treatment. 

In  South  Manchester,  of  1,725  pupils  examined  in  ele- 
mentary and  high  schools,  276  children  had  enlarged  ton- 
sils, or  1 6  per  cent;  27  of  the  276,  or  9.7  per  cent,  had 
had  operations  before  the  report  in  June. 

In  Winchester,  with  an  elementary  school  enrollment 
of  1,505  pupils,  after  several  years  of  thorough  inspection, 
138  cases  were  found,  or  8.5  per  cent;  and  62  of  the  cases, 
or  45  per  cent,  had  operative  treatment. 

In  Montclair,  among  3,255  elementary  children  only 
60  cases,  less  than  2  per  cent,  were  found,  but  of  these  37, 
or  6 1  per  cent,  had  operations. 

Some  of  the  other  figures,  where  known,  are  as  follows : 

*Dr.  Reik's  helpful  little  book  on  "Safeguarding  the  Special  Senses," 
F.  A.  Davis  Co.,  Philadelphia,  gives  an  excellent  illustration  of  visible 
adenoids  and  tonsils,  page  108. 


AILMENTS  OF  SCHOOL   CHILDREN       159 


ENLARGED  TONSILS 


No. 

Elementary  Prob- 

School  able 

Children  In-  Num- 

spected  or  ber  of 

Examined.  Cases. 


Percent- 
age of 

Ailments 
Given 


Summit    Exams....        1,034 


Num- 

Per-    ber  of 
cent-  Opera-     Operative 
age  De-  tions  Re-    Treat- 
fective.  ported.        ment. 

1 1.2 


Referred 


S.  Manchester  . . 
Winchester 

Montclair    

Brockton    

Waterbury    .... 

Yonkers    

N.  Bedford 
Trenton  Exams. 


Cambridge    

Lowell    

Rochester  Exams. 

Providence 

Newark    Exams.. 
Boston    


1,725 
1,505 

7,589 
12,077 
12,562 

10,587 


15,445 
u,438 
15,157 
5,6oi 
24,310 
61,055 


276 


60 


M 


16 
8.5 

2 

21% 


27 
62 

37 
125 


130          i  "Many." 

1,235          9.8  195 

7U         6  31 

1,723  (510)30%  16.4  50 
Referred 


9-7 
45 
61 

7.7 

15 
4-3 
2.9 


300 

721 
4,452 

272 
4,588 
4,101 


2       "366  home  visits" 

6.3  175  24 

29  Not  separately  given 

4-9  207  75 

18.8  416  9 

6.7      913  22.2 


195,079      20,458 


159.6  2,238  275.8 

10.6  25. 

average  average 

10.7  9,808  28. 


N.  Y.  City  (1911).   230,243       34,639 

RESULTS 

What  conclusions  can  we  draw  from  these  variant  facts  ? 
The  average  percentage  of  cases  of  enlarged  tonsils,  as 
compared  with  the  number  of  children  examined,  inspected, 
or  the  entire  elementary  school  enrollment,  as  the  case  may 
be,  is  10.6  per  cent,  while  the  average  percentage  of  these 
cases  given  operative  treatment  is  25.  In  Summit,  where 
we  are  given  the  facts,  only  39  referable  cases  were  found 
among  the  1,034  children  examined,  or  3.7  per  cent,  al- 
though the  number  of  recorded  or  minor  cases  is  11.2  per 
cent.  In  Trenton,  only  510  referable  or  serious  cases  were 
found  among  10,587  children  examined,  or  4.7  per  cent, 
although  the  total  number  of  cases  recorded  makes  a  per- 


160    SCHOOL  HEALTH  ADMINISTRATION 

centage  of  16.4.  These  figures  alone  would  lead  us  to 
suspect  that  the  number  of  real,  or  serious,  cases  would 
not  for  all  cities  give  a  percentage  as  high  as  10.6.  From 
this  and  personal  observation,  I  should  say  that  each  of  the 
five  figures  above  15  per  cent  could  be  divided  by  two  and 
a  more  accurate  statement  of  the  number  of  cases  of 
enlarged  tonsils  obtained.  One  reason  for  this  is  that  the 
examination  covered  only  a  part  of  the  school  population, 
while  children  were  inspected  from  all  parts.  Likewise,  it 
is  believed,  but  cannot  be  demonstrated,  that  in  those  cities 
with  percentages  of  cases  less  than  6,  physical  examinations, 
or  even  careful  inspection  for  the  purpose,  would  increase 
the  figures  up  to  six  or  more.  These  changes  would  make 
an  average  of  a  little  over  eight  per  cent.  Half  or  two- 
thirds  this  sum  would  be  near  the  number  of  serious,  refer- 
able cases,  perhaps. 

As  a  general  estimate  and  conclusion,  we  judge  that 
not  far  from  eight  per  cent  of  elementary  school  children 
have  enlarged  tonsils,  and  that  about  five  or  six  per  cent 
have  serious  referable  cases  which  should  probably  have 
operative  treatment.  Probably  half  to  two-thirds  of  these 
children  would  need  to  be  operated  on  for  adenoids  at  the 
same  time. 

Whether  cities  that  have  had  medical  "inspection"  for 
some  time  are  freer  from  this  ailment  than  others  not  hav- 
ing had  it,  cannot  be  told  from  these  figures.  The  average 
for  the  newer  systems  is  below  that  for  the  old.  Meriden 
and  Jersey  City,  practically  started  in  this  year,  have  given 
few  or  no  facts.  Whether  the  older  cities  had  found  fewer 
cases  each  year  is  also  difficult  to  determine.  Ideals  and 
standards  for  the  work  change.  Generally,  when  a  system 
is  beginning,  every  slight  deviation  from  the  normal,  if 
nothing  more  than  a  bad  cold  and  a  slight  swelling  of  ade- 
noids and  tonsils  due  to  it,  is  recorded,  and  children  are 
excluded  in  great  numbers  for  relatively  trifling  reasons. 
Gradually,  the  physicians  and  nurses  see  that  they  will  get 
better  results  if  they  pick  out  only  the  serious  and  urgent 
cases;  keep  children  in  school  as  much  as  possible,  even 


AILMENTS  OF  SCHOOL  CHILDREN      161 

cases  of  pediculosis  (nits)  under  treatment;  and  then  make 
a  good  effort  to  get  these  important  cases  treated  and  cured. 
This  seems  to  be  the  road  toward  maximum  efficiency. 

As  to  the  Board  of  Health  versus  the  Board  of  Edu- 
cation problem,  we  notice  that  the  only  cities  giving  no 
attention  to  this  serious  ailment  of  childhood  are  boards 
of  health  (Mt.  Vernon,  Newton  and  New  Haven)  with 
the  exception  of  Jersey  City.  No  board  of  health  has  what 
might  be  called  physical  examinations  with  individual  health 
record  cards,  except  Rochester.  The  only  board  of  educa- 
tion city  among  three  or  four  that  have  almost  insignificant 
numbers  of  cases  found  is  Montclair.  With  the  exception 
of  Rochester  it  can  be  said,  in  general,  that  even  if  they 
(the  board  of  health  systems)  are  much  older  on  the  aver- 
age than  board  of  education  systems  they  are  very  much 
less  efficient  in  this  respect. 

The  proportion  of  school  population  seriously  affected 
in  one  year  is  about  6  per  cent. 

6.    DEFECTIVE   VISION 

Defective  vision  is  very  largely  a  school  ailment.  And 
here  again  the  work  is  almost  inextricably  intertwined  with 
other  departments.  In  Massachusetts,  Connecticut  and  to 
a  large  extent  in  New  York,  vision  tests  are  conducted  by 
teachers  and  principals.  In  several  places  the  nurse  does 
the  testing,  in  others  the  physician,  while  in  others  the 
physical  training  teachers  help.  This  shows  again  the  need 
of  one  integrated  Department  of  Hygiene  in  a  school  system 
under  one  director  where  we  now  have  the  following  scat- 
tered and  uncorrelated  agents:  doctors,  nurses,  physical 
training  teachers,  playground  instructors,  open-air  school 
teachers,  dentists,  sanitary  inspectors,  etc.  Perhaps  in  many 
cities,  as  at  Summit  and  Brockton,  the  nurses  can  be  made 
also  truant  officers.  Why  not  do  this  work  while  very  prob- 
ably at  or  passing  the  home  on  regular  nursing  visits? 

No  very  definite  and  fixed  standards  for  testing  the 
vision  were  found.  There  are  so  many  persons  doing  the 
work,  even  where  each  principal  of  a  school  tests  all  his 


1 62     SCHOOL  HEALTH  ADMINISTRATION 

own  pupils,  that  the  results  must  be  taken  with  reservations, 
and  comparisons  made  only  with  great  care.  The  Snellen 
test  charts  are  the  ones  principally  used.  Some  call  all 
vision  less  than  20/20  defective;  others,  less  than  20/30; 
and  all  use  their  judgment  in  referring  cases  showing  signs 
of  eye-strain,  even  though  20/20  may  be  easily  read.  The 
Massachusetts  directions  for  testing,  as  given  in  "Medical 
Inspection  of  Schools,"  by  Gulick  and  Ayres  (1913  edi- 
tion), page  45,  are  also  commonly  followed.  The  great 
number  of  such  cases  declared  negative,  or  not  needing 
glasses,  after  examination  by  oculists  throw  doubt,  however, 
on  the  20/20  or  20/30  standards.  It  is  normal  for  there 
to  be  some  variation  in  the  vision  of  children;  indeed  varia- 
tion is  the  most  characteristic  thing  about  children.  This 
whole  problem  needs  investigation  under  competent  super- 
vision. Perhaps  20/30  or  less,  as  used  in  Newark,  would 
be  a  better  division  line.  We  recommend  20/40,  unless 
there  are  other  serious  symptoms  of  eye-strain. 

The  Providence  Board  of  Health  has  a  school  oculist 
who  gives  a  very  detailed  report  of  his  findings,  but  not 
of  his  methods,  in  the  1910  report.  He  devotes  two  morn- 
ings a  week  to  the  examination  of  children  referred  to  him 
by  the  school  doctors.  His  salary  is  $500  a  year.  Free 
prescriptions  for  glasses  are  given  all  needy  children.  We 
need  free  prescriptions  by  the  best  school  oculists  for  all 
school  children. 

In  Summit  we  find  the  following  report  by  the  phy- 
sician: "Eyes. — While  the  total  number  of  cases  with  defec- 
tive vision  and  various  other  diseases  of  the  eyes  is  rather 
in  excess  of  last  year  (194  and  185),  yet  more  than  one- 
third  of  this  number  is  made  up  of  last  year's  cases,  which 
are  almost  all  being  treated  by  properly  fitted  glasses.  It 
is  gratifying  to  note  that  when  attention  is  called  to  the 
need  of  correction  of  defective  vision,  the  parents  as  a 
rule  attend  to  the  matter  promptly.  Two  cases  of  severe, 
chronic  trachoma  (granulated  lids)  were  operated  on,  with 
complete  cure.  One  pupil,  16  years  old,  had  such  bad 
eyesight  that  he  could  only  see  letters  at  fifteen  feet  distance 


AILMENTS  OF  SCHOOL  CHILDREN      163 

which  he  should  have  been  able  to  see  at  eighty  feet.  There 
was  a  constant  eye-strain  and  twitching  of  the  lids,  which 
was  completely  cured  by  proper  glasses,  and  his  vision,  by 
their  means,  is  now  normal.  Some  pupils,  by  wearing 
glasses  for  a  time,  have  had  their  vision  so  much  improved 
that  glasses  are  no  longer  necessary,  and  the  accompanying 
eye-strain,  school  headaches,  watery  eyes,  etc.,  have  dis- 
appeared. In  all,  eighty-five  new  cases  of  defective  vision 
were  advised  to  consult  an  oculist."  The  nurse  reports 
having  "spent  twenty-four  afternoons  at  Dr.  Vaughan's, 
the  eye  specialist's,  with  children  whose  eyes  needed  atten- 
tion." 

The  facts  for  defective  vision,  as  nearly  as  they  could 
be  obtained,  are  as  follows : 

DEFECTIVE  VISION 


Summit     

No.  Elem. 
children 
examined. 

1  034 

Probable 
number 
of  cases. 

194 
60 
220 
51 

247(1457) 
562(6568) 
676 
637 
619 
194 
685* 
3003 
2000 

Per- 
centage. 

19     (8) 
3.8 
15 
1.5 

'3     (17) 

5.5(8) 
5.4 
5.4 
5.8 
1.2 
2 
12.4 
3.3? 

,  .  .82.8 

Percentage 
Number  of  num- 
obtained     ber  of 
glasses.      cases. 

a                     6 
5                   8.3 
70                29 
47 
75 
82                 33 
21                    3 
212                 31 

67                 11  ' 
'     14                    7 
250?               36? 
989                 32 
1742?               87? 

277.3 
28 

Norwood    

1  571 

El.  Pup. 
El.  Pup. 
El.  Pup. 
Exam'd. 
Exam'd. 
El.  Pup. 
El.  Pup. 
El.  Pup. 
Exam'd. 
El.  Pup. 
El.  Pup. 
Exam'd. 
Insp'cd. 

Winchester 

1  505 

Montclair     

3  255 

Meriden 

...      3  621 

Hoboken           .  . 

.  .    .  .    8  773 

Schenectady      .  .  . 
Yonkers            .  . 

10,121 
12  562 

New   Bedford    .  .  , 

,  11,839 

Trenton 

10,587 

Cambridge 

15  445 

Providence 

31  946 

Newark 

24  310 

61  055 

Average 

.    6.4 

a85  referred.     &"Almost  all."     *491  prescribed  glasses.      ?Treatment. 

Here  again  records  are  such  that  scientific  data  are 
hardly  obtainable,  and  generalization  must  proceed  cau- 
tiously. On  the  stand  that  only  referable  cases  should  be 
reported,  Summit  would  have  a  percentage  of  the  number 
of  elementary  school  children  examined  of  about  8,  instead 
of  19.  The  same  would  probably  hold  true  of  Winchester 
and  of  Newark.  Very  low  figures  below  4  are  probably  due 
to  the  fact  that  there  were  visual  examinations  made  of  only 
a  part  of  the  elementary  school  population,  those  referred 
by  teachers,  and  those  who  were  found  by  a  partial  routine 


1 64    SCHOOL  HEALTH  ADMINISTRATION 

examination.  The  percentages  of  cases  found  here  are 
smaller  than  those  usually  given. 

From  my  observations,  and  from  these  data,  I  am 
convinced  that  most  of  the  high  percentages  given  in  reports 
of  medical  inspection  are  unnecessarily  alarming,  since  they 
really  mean  little  when  carefully  analyzed.  They  are  prac- 
tically always  based  upon  the  number  of  cases  found  by 
the  standard  used,  and  not  by  the  number  of  cases  referred 
for  treatment,  which  is  nearer  the  actual  number  of  genuine 
cases.  Many  of  the  latter  even  are  only  "suspected"  cases 
on  which  the  parents  are  advised  to  obtain  advice.  More 
confidence  must  be  placed  in  careful  examinations,  but  even 
these  vary  considerably  in  the  above  list.  Where  physical 
examinations  were  made,  as  in  the  case  of  Newark,  of  only 
part  of  the  elementary  pupils,  and  cases  referred  for  vision 
tests  from  among  the  non-examined  children,  we  must  lower 
the  percentages. 

As  a  final  judgment,  I  should  say  that  the  average  given 
above  is  not  very  far  from  the  actual  percentage  of  ele- 
mentary school  children  with  this  defect,  when  the  examina- 
tion has  covered  all  grades.  Perhaps  not  far  from  7  per 
cent  of  elementary  school  children  will  be  found  to  need 
glasses  as  a  remedy  for  their  defective  vision.  This  would 
mean  two  or  three  children  in  each  school  room.  The 
number  will  be  found  to  increase  with  age.  This  estimate 
Is  practically  that  made  by  eight  ophthalmic  surgeons  who 
by  special  appointment  examined  2,000  school  children  in 
London  in  1904.*  Their  examinations  demonstrated  that 
about  7.3  per  cent  of  all  children  in  the  elementary  schools 
suffer  from  20/60  or  worse  vision.  The  percentage  near 
20/40  and  less  was  12.6.  This  last  seems  to  be  about  the 
standard  used  at  Newark,  although  in  reality  it  is  given 
as  20/30. 

The  relative  numbers  of  cases  of  various  kinds  are 
given  in  great  detail  in  the  1910  report  of  the  Providence 

*Cornell,  page  579. 


AILMENTS  OF  SCHOOL   CHILDREN      165 

Board  of  Health,  of  which  the  following  is  a  section  with 
percentages  computed: 

Vision  Number  of  eyes  Percentage 

20/15  I2?  IO 

20/20  201  16 

20/30  243  20 

20/40  167  14 

20/50  95  8 

20/70  162  14 

20/100  159  13 

20/200  127  10 

There  were  685  cases  which  had  been  found  by  teachers, 
nurse  and  physicians;  and  for  these  the  oculist  prescribed  491 
pairs  of  glasses,  or  nearly  72  per  cent.  Ten  eyes  (not  chil- 
dren) were  found  with  a  total  loss  of  vision;  and  28  children 
with  supposed  defective  vision  were  found  to  be  only 
illiterate. 

The  question  of  whether  vision  testing  should  be  done 
only  by  oculists  has  not  been  scientifically  answered.  Prac- 
tically, doctors,  nurses,  and  teachers  in  the  various  cities 
simply  find  the  cases  which,  according  to  rough  estimates, 
should  receive  examination  by  an  oculist.  Until  we  have 
clinics  which  will  furnish  prescriptions  and  possibly  glasses 
at  public  expense,  as  school  books  are  now  furnished,  the 
present  system  will  probably  be  best.  Another  alternative 
is  to  do  as  Providence  has  done  in  supplying  accurate  diag- 
nosis with  prescriptions  for  glasses  to  all  who  desire  it,  and 
are  recommended  by  the  nurses,  and  glasses  to  those  only 
who  are  unable  to  pay  for  them. 

The  nurses  have  been  very  successful  in  many  cities  in 
helping  needy  children  to  obtain  glasses.  In  practically 
every  city  there  are  numerous  individuals  and  organizations 
that  are  glad  of  the  chance  to  furnish  glasses  to  the  children 
of  needy  parents.  In  Lowell,  Superintendent  Whitcomb  has 
for  years  furnished  needy  children  with  money  for  glasses 
out  of  his  own  pocket.  Such  sacrifice  is  needless,  and  stands 
in  the  way  of  acquainting  the  public  with  school  problems 


1 66    SCHOOL  HEALTH  ADMINISTRATION 

and  school  needs.  The  numerous  ways  devised  by  superin- 
tendents and  others  in  obtaining  assistance  along  a  great 
variety  of  health  lines  without  school  expenditure  and  with 
benefit  to  the  public,  as  found  in  a  number  of  the  cities 
visited,  almost  leads  to  the  conclusion  that  a  superintendent 
can  get  almost  anything  he  wants  for  the  schools  free  of 
charge,  if  he  knows  how  to  mould  public  opinion  and  reach 
the  people  who  desire  to  give  services  or  money  or  both  to 
some  worthy  cause.  Denison's  book  on  "Helping  School 
Children"  (Harper's)  is  full  of  illustrations  of  this  prin- 
ciple, and  points  out  an  almost  unworked  field  before  us. 

BOARDS  OF  HEALTH  VS.  BOARDS  OF  EDUCATION 

What  does  the  comparative  treatment  of  defective  vision 
in  the  schools  show  as  to  the  relative  efficiency  of  Boards 
of  Education  and  Boards  of  Health?  Of  four  cities  giving 
no  attention  to  this  very  important  school  ailment,  three 
were  board  of  health  cities.  In  New  Bedford,  where  the 
doctors  but  not  the  nurses  are  under  the  Board  of  Health, 
the  former  have  practically  neglected  this  ailment,  finding 
only  five  cases  to  the  nurse's  632.  There  is  good  excuse  for 
this  perhaps  in  that  teachers  are  required  by  law  to  make 
such  examinations  in  Massachusetts.  This  would  practically 
excuse,  also,  the  other  boards  of  health  in  other  cities,  for 
this  ailment.  By  far  the  best  report  on  this  subject  is  found 
in  the  report  of  the  Board  of  Health  of  Providence,  and 
the  1911  report  is  still  better.* 

In  the  cities  given  in  the  above  table,  however,  where 
boards  of  health  have  attempted  this  work,  we  could  com- 
pare the  two  forms  of  administration  on  the  following  bases 
for  which  we  have  data : 

a.  Percentage  of  elementary  school  children  examined 
for  vision. 

b.  The  percentage  of  cases  found. 


*In  general,  the  reports  on  Medical  Inspection  by  Dr.  Charles  V. 
Chapin,  of  this  Board  of  Health,  are  in  many  ways  quite  superior  to 
those  of  many  or  most  other  cities. 


AILMENTS  OF  SCHOOL   CHILDREN      167 

c.  The  percentage  of  cases  procuring  glasses,  or  other 
treatment. 

The  quality  of  the  work  done  in  examination  cannot  well 
be  put  in  the  form  of  a  numerical  coefficient,  although  we 
could  say  that  the  examinations  of  the  oculist  at  Providence 
were  undoubtedly  better  than  those  in  other  cities.  The 
amount  of  work  is  shown  to  some  extent  by  the  number  of 
cases  found;  for  those  cities  reporting  percentages  less  than 
three  or  four  of  the  elementary  school  population,  certainly 
did  not  reach  all  the  children.  Six  cities  fall  below  four 
per  cent,  3  under  the  boards  of  health.  But  there  are,  in  all, 
9  board  of  education  cities  to  6  board  of  health  cities,  and 
one  of  the  latter,  Boston,  is  partly  administered  by  the  Board 
of  Education.  This  would  give  the  advantages  to  the  boards 
of  education,  the  percentages  falling  below  being  about  33 
for  the  boards  of  education  and  50  for  the  boards  of  health. 
Both  Boston  and  New  Bedford,  especially  the  latter,  are 
lifted  up  by  the  school  nurses  in  the  department  of  education. 

The  three  cities  with  high  percentages  are  all  board  of 
education  cities.  These  higher  percentages!  may  not  be 
virtues  where  discretion  has  not  been  used.  In  these  three 
cases,  however,  I  think  they  represent  careful,  painstaking 
work  with  a  large  percentage  or  all  of  the  children. 

GLASSES 

Little  can  be  judged  from  these  figures.  The  average 
percentage  of  cases  treated  or  cured  by  glasses  for  the  ten 
cities  reporting  is  28.  The  average  for  the  board  of  health 
cities  is  1 1  per  cent,  while  the  average  for  the  boards  of 
education  is  33.  Boston  is  here  counted  as  a  board  of  edu- 
cation city  for  this  function,  since  the  nurses  reported  1,581 
cases  to  the  doctors'  617,  and  were  the  ones  who  got  the 
treatments  and  recorded  them. 

The  following  conclusion  can  probably  be  drawn  legiti- 
mately from  these  facts : 

As  a  rule,  these  boards  of  health  are  less  efficient  than 
.are  these  boards  of  education  with  respect  to  finding  cases 


1 68     SCHOOL  HEALTH  ADMINISTRATION 

of  defective  vision,  and  especially  in  obtaining  and  reporting 
cures. 

Providence  stands  out  as  an  exception. 

I9II   REPORT  OF  THE  PROVIDENCE  OCULISTS 

This  leads  us  to  add  some  further  facts  from  the  last 
Providence  report  on  this  problem  of  finding  and  curing 
defective  vision. 

Two  oculists  are  now  employed  (1911  Report)  two 
afternoons  a  week  for  about  two  hours  each  afternoon  at 
the  Fourth  Ward  Room  for  examining  eyes,  at  salaries  of 
$500  each.  All  pupils  who  are  found  with  defective  vision 
in  the  schools  by  teachers  or  nurses  may  now  go  to  these 
oculists  for  free  examinations  and  prescriptions  for  glasses, 
or  medical  treatment.  One  oculist  has  reported  for  only  a 
half  year.  Together,  there  were  646  cases,  for  whom  were 
prescribed  496  pairs  of  glasses  (77  per  cent)  and  of  whom 
the  nurse  saw  420  and  obtained  or  reported  339  as  "having 
treatment,"  which  if  we  were  to  interpret  as  meaning  glasses, 
would  be  68  per  cent  of  the  number  prescribed  glasses,  and 
8 1  per  cent  of  the  cases  seen  by  the  nurse.  A  small  per- 
centage of  the  cases  needed  medical  treatment.  Two  pos- 
sible fallacies  lie  here :  There  were  probably  many  children 
with  defective  vision  who  did  not  go  to  these  oculists,  so  the 
percentage  of  cases  treated  was  probably  much  smaller,  and, 
second,  treatment  may  mean  glasses  in  only  a  small  per- 
centage of  cases. 

This  illustrates  again  the  common  failing  to  give  the 
facts  upon  which  estimates  can  be  made,  even  in  the  best 
reports.  (Our  estimate  of  children  needing  glasses  or  an 
operative  treatment  is  seven  per  cent.) 

7.  STRABISMUS,  CROSS-EYE,  SQUINT 

This  is  a  vision  defect  which  is  emphasized  by  separation 
from  the  others.  Dr.  Reik,  in  his  "Safeguarding  the  Special 
Senses,"  expresses  sound  medical  experience  when  he  says, 
that  "practically  all  cases  of  crossed  eyes,  even  of  many 
years  standing,  can  be  rectified,  and  when  one  considers  what 


AILMENTS  OF  SCHOOL   CHILDREN      169 

a  difference  in  personal  appearance  it  makes,  the  disagreeable 
effect  of  such  an  eye  upon  those  who  must  come  in  contact 
with  the  afflicted  person,  and  the  simplicity  of  the  operation, 
it  looks  like  a  sin  against  the  community  to  allow  such  per- 
sons to  retain  their  deformity"  (page  46).  The  ailment  is 
only  the  failure  of  the  eyes  properly  to  co-ordinate  because 
of  muscular  or  refractive  errors,  and  the  giving  up  of  the 
struggle  to  use  both  eyes  together.  One  only  is  used,  and  if 
the  other  is  constantly  neglected  through  habit  or  other  cause 
it  frequently  goes  blind.  So  this  ailment,  which  is  quite 
commonly  neglected,  should  be  given  special  attention  in 
early  school  life,  or  before,  whenever  the  nurse  or  teacher 
finds  such  a  case  among  the  little  children  in  the  homes. 

Some  cities  did  not  keep  separate  records  of  this  ailment, 
and  several  did  not  record  the  ailment  at  all.  There  were 
two  cases  in  Summit  among  1,034  children.  Waterbury  had 
89  cases  in  an  elementary  school  population  of  12,077,  a 
much  larger  percentage,  but  little  less  than  one  per  cent  (.7) . 

Yonkers  reports  47  cases  found  by  the  doctors.*  Taking 
47,  we  have  a  percentage  of  the  elementary  school  enroll- 
ment of  .4.  Taking  the  several  cities,  and  using  the  nurses' 
figures  for  Cambridge  and  the  physicians'  in  Boston  as  is 
reasonable,  we  have: 

Children.  Cases.  Percentage. 

Waterbury    12,077  89  .7   (7  in  1000) 

Yonkers    12,562  47(25)  4  (•*) 

New  Bedford   11,839  221  1.8   (iSiniooo) 

Trenton    12,774  26  -2 

Cambridge    15445  95  -6 

Providence    31,946  ioof  .3 

Boston    95,970  173$  -2 

4.2 

Average  .6,  or  6  in  a  1000. 
fOculist.     JPerhaps  more. 

Leaving  out  New  Bedford  with  its  high  figures,  we  have 
a  percentage  of  .4,  or  four  in  one  thousand  elementary 

*Our  summary  of  the  doctor's  reports  shows  only  25  cases;  while 
the  nurse  reports  12  cases  treated,  while  our  summary  of  her  reports 
shows  only  6  cases. 


i  yo    SCHOOL  HEALTH  ADMINISTRATION 

school  children.  Nothing  has  yet  been  brought  out  to  show 
whether  the  ailments  of  any  kind  vary  much  with  place  and 
length  of  time  these  medical  inspection  systems  have  been  in 
operation.  Our  estimate  is  about  seven  cases  in  a  thousand. 

Very  few  of  these  cases  are  reported  as  having  had  treat- 
ment, operations,  or  glasses.  This  is  due  only  partly  to  ineffi- 
ciency. Physicians  and  nurses  are  frequently  not  sure  that 
it  is  necessary  or  their  province  to  follow-up  thoroughly  all 
cases  to  see  that  they  do  obtain  the  care  they  need.  A  later 
chapter  will  show  that  they  do  not  get  results  amounting  to 
very  much  without  thorough  follow-up  work,  and  it  is  ap- 
parent that  neither  tests  of  efficiency  nor  adequate  knowledge 
of  health  facts  can  be  obtained  without  satisfactory  records 
of  the  most  important  matter  in  all  this  work,  cure  and  pre- 
vention. 

(Our  estimate  is  7  cases  in  a  thousand.) 

8.  GLANDS  ENLARGED,  ADENITIS,  TUBERCULAR  LYMPH 

NODES 

This  is  another  ailment  quite  common  to  children  and 
which  may  lead  to  serious  consequences,  the  least  of  which 
may  be,  if  Ayres'  findings  *  are  true,  serious  retardation  in 
school,  amounting  to  a  loss  of  1.2  years  in  passing  through 
the  elementary  school.  Other  causal  factors  operate,  how- 
ever, with  such  cases  and  we  are  not  sure  that  the  retardation 
may  not  have  been  due  in  whole  or  in  part  to  poverty,  bad 
heredity  or  some  other  associated  cause.  Verification  of  such 
studies  lies  in  the  future. 

Malnutrition,  bad  ventilation,  and  decayed  teeth  are 
named  by  physicians  as  causes  of  this  ailment,  though  they 
give  but  little  scientific  proof  of  their  conclusions.  One  very 
clear  route  of  travel  to  adenitis  seems  to  lie  through  the 
following  steps:  decayed  teeth,  enlarged  tonsils,  adenoids 
and  indigestion,  then  enlarged  glands.  Frequently  the  route 
is  also  up  the  eustachian  tubes  to  otitis  media,  or  discharging 
ears  and  deafness.  The  glands  may  also  become  tubercular 

*Laggards,  page  128,  and  the  1913  edition  of  Medical  Inspection 
of  Schools,  page  161. 


AILMENTS   OF  SCHOOL  CHILDREN       171 

and  consumption  may  follow.  The  mouth  is  the  portal. 
Much  of  medicine,  as  of  education,  is,  however,  yet  a  matter 
of  mere  hypothesis. 

So  few  of  the  gland  cases  are  recorded  as  treated  or 
cured  that  a  separate  column  is  not  given  to  these  data  in  the 
table.  Something  of  the  frequency  of  the  ailment  may  be 
gleaned  from  the  data  below: 

ENLARGED  GLANDS 

Per-          Re-    Reported 
Cases.       centage.     ferred.  Treated. 

Summit    1,034  Exam'd.  103  10.0 

S.   Manchester   1,725  Exam'd.  2  .1               2 

Norwood   i,57i  El.  Pup.  8  .5              8 

Winchester    1,505  El.  Pup.  18  2.3             18 

Montclair    3,255  El.  Pup.  25  .8             25              10 

Hoboken     8,773  Exam'd.  5  .o               5 

Schenectady     10,121   El.  Pup.  29  .2 

Waterbury 12,077  El.  Pup.  114  .9              .. 

Yonkers    3  .o 

New  Bedford   11,839  El.  Pup.  15  .1 

Trenton    10,587  Exam'd.  10  .1              10 

Cambridge    15,445  El.  Pup.  30  .2             30 

Syracuse    18,016  El.  Pup.  39  .2 

Rochester    15,157  Exam'd.  1281  1.2 

Providence    31,946  El.  Pup.  70  .2 

Newark   24,310  Exam'd.  4147  1.7 

Boston    61,055  El.  Pup.  700  i.i 


Average  1.2  per  cent  for  15  cities.  28.6  percent. 

Here  we  have  percentages  of  this  ailment  far  below  on 
the  average  those  usually  given.  In  the  controlled  investiga- 
tion by  Ayres  in  1908  previously  mentioned,  among  7,608 
children  medically  examined,  a  percentage  of  40  per  cent 
were  found  suffering  from  enlarged  glands  in  the  six-year 
group  and  7  per  cent  in  the  1 5-year  age  group.  The  per- 
centage for  all  is  not  given.  Among  3,304  of  those  above 
the  age  of  nine  especially  studied,  over  13  per  cent  had  en- 
larged glands;  and  when  they  were  divided  into  three  classes 
the  percentages  were  as  follows:  Dull,  20;  Normal,  13; 
Bright,  6. 

None  of  the  figures  in  these  twenty-five  cities  approach 


172    SCHOOL  HEALTH  ADMINISTRATION 

very  closely  to  this  average.    The  conclusions  which  might 
be  drawn  to  account  for  this  discrepancy  are : 

a.  Summit  and  Newark  were  the  only  cities  which  made 
very  thorough  examinations  of  the  children.    There  is  some 
truth  in  this. 

b.  These  cities  have  not  found  all  the  cases.     There  is 
also  some  truth  in  this. 

c.  The  New  York  children  are  more  afflicted  with  this 
ailment.     I  doubt  whether  there  is  very  much  truth  in  this. 

d.  The   New   York  physicians   found  more   cases   than 
there  were,  or  called  very  slight  deviations  from  the  normal, 
enlarged  glands.     If  there  is  much  truth  in  the  last  hypoth- 
esis, Ayres'  findings  rest  on  a  very  unstable  basis.    The  time 
is  not  ripe  to  be  dogmatic  in  this  field. 

In  the  entire  city  of  New  York  in  the  school  year  of 
1910-11  among  230,243  children  examined,  only  483  cases 
were  found,  a  percentage  of  .2,  the  average  above  given. 
The  1912  monograph  on  "The  Division  of  Child  Hygiene," 
of  the  Department  of  Health  of  the  City  of  New  York, 
shows  also  no  great  variations  by  ages,  as  shown  on  the 
chart,  part  82.  The  percentages  for  1910  and  1909  are 
practically  .3.  These  figures  throw  more  suspicion  upon  the 
accuracy  of  the  Ayres'  data. 

What  general  statement  of  the  prevalence  of  this  defect 
can  we  derive  from  the  above  data  ?  Some  cities  apparently 
found,  or  at  least  recorded,  no  cases  at  all.  One  would  not 
expect  to  find  a  high  percentage  of  these  cases  in  Summit, 
it  being  probably  one  of  the  most  healthful  and  generally 
well-to-do  of  the  cities,  a  suburban  resident  town.  There 
seems,  however,  to  be  little  sociological  basis  for  the  varia- 
tions, the  mill  towns  and  others  with  congested  foreign 
population  not  standing  very  high,  comparatively.  The 
length  of  time  medical  inspection  has  been  in  force  seems  to 
make  no  difference.  The  difference  must  lie  more  in  the 
standards,  requirements,  and  interests  of  the  men  and  women 
making  the  examinations  and  inspections. 

Special  studies  in  England  of  some  10,000  children  place 


AILMENTS  OF  SCHOOL  CHILDREN      173 

the  percentage  of  cases  below  one  per  cent  as  in  most  of 
the  cities  in  this  investigation.* 

The  number  of  cases  in  Summit  was  very  much  smaller 
the  year  before  the  above  report,  the  exact  figures  not  being 
given;  but  among  950  pupils  examined  there  are  only  91 
(about  10  per  cent)  miscellaneous  cases  of  "anemia,  mal- 
nutrition, coughs,  colds,  nervous  affections,  glandular  swell- 
ings, etc."  Undoubtedly,  the  percentage  was  very  low;  and 
yet  the  Ayres'  figures  for  the  retarding  effect  of  glands  are 
given  in  the  same  report.  In  the  later  report  studied, 
1910-11,  the  doctor  says  in  his  report,  "Glands — Particular 
attention  was  paid  to  enlarged  glands  of  the  neck.  These 
usually  accompany  decayed  teeth  and  are  apt  to  break  down, 
or  become  tubercular  unless  prophylactic  treatment  is  given. 
There  were  103  cases."  None  were  referred  according  to 
the  following  statistical  table  in  the  report.  This  is  a  glaring 
example  of  a  point  made  by  the  writer  on  a  former  page,  that 
physicians  find  what  they  give  "attention"  to,  what  they  look 
for;  and  the  Summit  physician  is  quite  above  the  average 
medical  inspector. 

Discounting,  then,  very  much  the  Summit  percentages, 
we  have  Newark  to  consider.  The  previous  report  shows 
a  percentage  of  16  for  this  defect.  My  judgment  is  that 
very  slight  deviations  from  type  for  this  defect  are  recorded, 
rather  than  that  the  children  are  especially  ailing  in  this 
particular.  Then,  too,  many  children  not  among  the  24,310 
examined,  undoubtedly  furnished  cases.  The  probabilities 
are  that  the  true  percentage  is  not  above  four  per  cent  at 
most.  Trenton  and  Rochester  both  had  physical  examina- 
tions and  their  percentages  are  only  .1  and  1.2. 

Taking  a  number  of  such  facts  into  consideration  we 
should  estimate  that  the  actual  number  of  cases  in  the  ele- 
mentary school  populations  serious  enough  to  warrant  atten- 
tion and  preventive  or  curative  measures  is  around  one  per 
cent,  as  a  fairly  generous  estimate.  Not  until  there  is  some 

*i9io  report  of  the  Chief  Health  Officer  of  the  English  Board  of 
Education,  pages  53  and  54. 


174    SCHOOL  HEALTH  ADMINISTRATION 

adequate  standardization  of  reporting  this  and  other  ail- 
ments through  the  training  and  supervision  of  physicians 
and  nurses  will  there  be  much  correspondence  among  reports. 

9.  HEART  DEFECTS,  HEART  DISEASE,  CARDIAC  AILMENT 

The  1911  report  of  the  Board  of  Education  of  England 
above  mentioned  summarizes  the  situation  here  with  respect 
to  this  ailment,  in  the  following  words:  "As  far  as  can  be 
judged  from  the  attention  bestowed  on  this  subject  in  the 
reports  of  School  Medical  Officers,  it  does  not  appear  as 
yet  to  have  aroused  widespread  interest  or  to  have  formed 
the  basis  of  many  special  inquiries"  (page  54).  We  have 
nothing  in  America  comparable  to  this  report,  however.  The 
percentage  of  children  affected  seems  to  be  about  one  per 
cent. 

Without  placing  here  all  the  figures,  the  reasoning  and 
the  guessing  necessary,  we  shall  give  in  this  and  several  other 
cases  only  the  probable  frequency  of  the  ailment,  with  the 
variabilities. 

Some  of  the  cases  are:  Summit,  .3  per  cent;  Boston,  .2 
per  cent;  Rochester,  .5  per  cent;  Newark,  i  per  cent;  Tren- 
ton, i.i  per  cent;  Hoboken,  1.4  per  cent.  In  New  York  City 
in  1911,  the  percentage  is  .7.  The  average  for  our  cities  is 
less  than  .7. 

Discounting  for  recording  very  minor  cases,  and  adding 
for  the  cases  missed,  we  judge  that  the  number  of  the  vari- 
ous kinds  of  heart  defect  needing  attention  and  treatment  is 
between  .6  and  1.2  per  cent,  say  .9,  to  name  a  figure.  With 
better  education  in  this  respect,  and  all  examinations  made 
with  the  pupils'  chests  stripped,  the  percentage  of  real  cases 
will  probably  rise  to  one  per  cent.  Most  cities  do  not  have 
the  latter  necessity  for  adequate  heart  and  lung  examinations. 

10.  LUNGS  WEAK,  NOT  TUBERCULAR 

Some  children  are  flat  chested,  weak  lunged  and  predis- 
posed to  pulmonary  troubles,  but  not  yet  infected  with  tuber- 
culosis. They  need  good  ventilation,  physical  training  in  the 
form  of  plays  and  games  and  probably  medical  gymnastics, 


AILMENTS  OF  SCHOOL  CHILDREN      175 

light  work,  good  food  and  general  care.  These  are  the  ones 
who  are  anemic  and  debilitated,  and  frequently,  if  not 
always,  profit  in  an  open  air  school.  We  can  tell  little  about 
the  frequency  of  the  defect.  Depending  again  largely  upon 
cities  that  have  physical  examination,  we  have  an  average 
percentage  of  about  .5  or  a  half  a  per  cent,  five  cases  in  a 
thousand.  This  is  only  a  guess  because  the  defect  cannot  be 
well  defined. 

II.  MALNUTRITION,  DEBILITY,  INDIGESTION,  GENERAL  CON- 
DITION 

These  ailments  are  not  well  differentiated,  but  they  are 
not  separated  well  in  the  reports.  Debility  and  indigestion 
may  have  little  or  nothing  in  common  with  malnutrition. 
The  latter  term  is  most  commonly  represented  in  this  col- 
umn, however. 

The  percentages  for  some  of  the  cities  are  as  follows: 
Summit,  i  per  cent;  Norwood,  i  per  cent;  Montclair  (many 
cases  of  "general  condition"),  counting  124  cases,  4  per  cent; 
Hoboken,  .05  per  cent;  Waterbury,  say  30  cases,  .2  per  cent; 
New  Bedford,  .4  per  cent;  Trenton,  .4  per  cent;  Cambridge, 
.1  per  cent;  Rochester,  5  per  cent  (these  doctors  also  visit 
those  families  who  are  ill  and  in  poverty;  and  this  may  ac- 
count for  the  attention  given  to  malnutrition)  ;  Providence 
(100  cases),  .3  per  cent;  Newark,  2.6  per  cent,  and  Boston 
(counting  800  cases),  1.3  per  cent.  The  average  is  1.3. 
The  median  is  4  per  cent. 

There  are  undoubtedly  very  many  more  cases  of  under 
and  poorly  fed  children  in  many  of  these  cities,  as  could  be 
easily  determined  on  investigation,  probably  as  many  as  six 
or  seven  per  cent  in  some  cities  with  more  poor  and  more 
foreigners  than  Rochester.  This  problem  very  much  needs 
scientific  study,  and  school  systems  very  much  need  adjust- 
ment to  the  situation  as  found.  England  is  far  ahead  of  us 
in  this  particular.  Both  the  1910  and  1911  English  reports 
mentioned  give  able  treatments  of  this  matter.  Among 
about  200,000  children  examined  *  in  counties  and  urban 
districts,  approximately  20  per  cent  were  regarded  "good" 

*i9ii  Report. 


1 76    SCHOOL  HEALTH  ADMINISTRATION 

as  to  nutrition,  69  per  cent  "normal,"  10  per  cent  "sub- 
normal," and  a  little  less  than  one  per  cent  as  "bad."  These 
percentages  are  based  upon  the  medical  judgments  of  the 
physicians.  Attempt  at  objective  standardization  of  the 
examination  is  being  made  in  the  relationship  to  height  and 
weight,  pages  27-29. 

A  "nutritional  index"  was  worked  out,  namely:  Index 
equals  100  times  the  cube  root  of  the  quotient  of  the  weight 
in  kilograms  divided  by  the  height  in  kilograms. 

The  average  value  of  this  index  for  each  year  of  school 
age  from  three  to  fifteen  for  9,166  children  examined  was 
determined,  and  these  standards  used  for  measuring  the 
nutritional  condition  of  various  groups  of  children,  with  fair 
results. 

The  London  County  Council  publishes  a  book  largely 
given  over  to  the  problem  of  meeting  the  malnutrition  sit- 
uation (Handbook  Containing  General  Information  with 
Reference  to  Children's  Care,  second  edition,  R.  Blair,  Edu- 
cation Officer,  London). 

In  our  own  country,  and  among  these  cities  studied  my 
judgment  is  that  not  far  from  two  per  cent  of  the  elementary 
school  children  are  suffering  enough  from  malnutrition  to 
need  special  care  and  treatment.  In  New  York  City,  the 
percentage  is  from  2.5  per  cent  to  perhaps  3.5  per  cent. 

12.  DEFECTIVE  MENTALITY,  BACKWARD  CHILDREN 

Only  half  of  the  cities  mention  this  serious  defect.  Provi- 
dence has  since  employed  a  neurologist  for  the  examination 
and  study  of  such  cases,  but  further  than  that  there  seems 
to  be  no  specialization  of  this  function  as  at  Cleveland,  Los 
Angeles  and  other  places. 

Some  of  the  percentages  of  this  ailment  are  as  follows: 
Summit,  i  per  cent;  Norwood,  5.4  per  cent;  Winchester,  .1 
per  cent;  Montclair,  1.5  per  cent;  Schenectady  (47  cases), 
.  c  per  cent;  Waterbury,  .1  per  cent;  Trenton,  .1  per  cent; 
Cambridge,  .1  plus;  Providence,  .2  per  cent,  and  Newark, 
1.4  per  cent.  The  average  is  for  these  ten  cities,  .9.  This 
is  practically  the  number  found  in  Cleveland  by  the  psy- 


AILMENTS   OF  SCHOOL  CHILDREN       177 

chiatrist  with  the  help  of  the  Binet  tests,  but  according  to 
the  1911-12  report,  page  3,  "falls  far  short  of  the  total  num- 
ber in  the  public  schools."  A  distinction  is  made  between 
the  feeble-minded  and  the  mentally  defective  children,  "the 
epileptic  children  should  also  be  included  in  the  group  to  be 
eliminated"  from  the  schools.  This  would  raise  the  percent- 
age for  Cleveland  (750  cases  and  41,514  examined  by  doc- 
tors) up  to  1.8  per  cent.  Dr.  Holmes  of  Newark  also  urges 
the  elimination  of  all  such  children  from  the  schools.  Dr. 
Goddard  in  his  investigation  of  this  problem  for  the  School 
Inquiry  Committee,  concluded  that  there  are  at  least  15,000 
feeble-minded  children  in  the  public  schools  of  New  York 
City,  about  2  per  cent.  These  are  children  uso  mentally  de- 
fective as  to  preclude  any  possibility  of  their  ever  being  made 
normal  and  able  to  take  care  of  themselves  as  adults."  This 
is  also  the  percentage  found  among  2,000  children  in  the 
little  town  of  Camden,  N.  J.* 

Our  judgment  for  these  cities  is  that  the  actual  per- 
centage of  mentally  defective  children  in  the  elementary 
schools  is  not  far  from  one  per  cent. 

13.   NERVOUS  AILMENTS,   CHOREA,    HABIT  SPASM,   NERVOUS 

EXHAUSTION 

There  are  a  number  of  ailments  of  the  nervous  system 
which  are  frequent  among  children,  and  important  from  the 
educational  point  of  view.  These  are  well  treated  from 
the  medical  point  of  view  by  Cornell  and  Hoag  in  their 
books  on  "Medical  Inspection"  and  the  "Health  Index." 
We  are  concerned  here  principally  with  their  frequency  and 
administration.  Some  of  these  ailments  connected  with 
speech,  sex,  etc.,  are  treated  in  other  columns.  The  prin- 
cipal ones  here  are  chorea,  or  St.  Vitus'  dance,  a  nervous 
twitching  of  various  muscles  of  the  neck,  face,  head,  shoul- 
ders, arms  and  legs.  Dr.  L.  D.  Cruickshank,  in  his  most 
excellent  "Sixth  Annual  Report  on  the  Medical  Inspection  of 
School  Children  in  Dunfermline,"  Scotland,  says  it  is  "re- 


*See  Pedagogical  Seminary  for  June,   1911,  "Two  Thousand  Chil- 
dren Tested  by  the   Binet  Scale,"  by   Henry  H.   Goddard. 


178     SCHOOL  HEALTH  ADMINISTRATION 

garded  by  some  as  a  manifestation  of  rheumatism  and  as 
such  requires  special  care  in  order  that  no  damage  may  result 
to  the  heart.  Children  should  come  under  treatment  as  soon 
as  the  choreaic  movements  are  detected.  Continuance  at 
school  is  harmful  even  when  the  symptoms  are  slight  in 
character." 

Nervous  exhaustion  is  found  more  particularly  among  the 
girls  in  the  upper  grades  and  high  school.  Nervousness,  ex- 
citability, and  peculiar  nervous  habits  all  come  under  this 
list.  Epilepsy  is  included,  but  would  not  have  been  had  there 
been  many  cases  reported  (13  in  Boston).  A  few  other 
ailments  have  very  small  representation.  The  chapter  by  Dr. 
Cornell  in  his  book,  pages  324  to  358,  is  probably  the  best 
school  discussion  we  now  have  of  the  trouble.  Reports  from 
some  of  the  cities  are  as  follows : 

Summit    8  cases,  a  percentage  of  about  I      per  cent 

Montclair    20  cases,  a  percentage  of  about  .8  per  cent 

Hoboken    4  cases,  a  percentage  of  about  .04  per  cent 

Brockton    17  cases,  a  percentage  of  about  .2  per  cent 

Waterbury    ....     6  cases,  a  percentage  of  about  .06  per  cent 

Trenton    8  cases,  a  percentage  of  about  .07  per  cent 

Cambridge 14  cases,  a  percentage  of  about  .09  per  cent 

Providence     ....  134  cases,  a  percentage  of  about  .4  per  cent 

Newark    77  cases,  a  percentage  of  about  .3  per  cent 

Boston    130  cases,  a  percentage  of  about  .2  per  cent 


3.17 
Average,  .3  per  cent.     Median,  .3  per  cent. 

The  percentage  in  Dunfermline  is  .4  per  cent.  In  New 
York  City,  the  percentage  is  also  .4  per  cent.  Better  medical 
examination  and  inspection  in  our  upper  grades  and  high 
schools  will  undoubtedly  raise  this  percentage.  My  judg- 
ment for  the  elementary  schools  of  the  cities  is  that  its  fre- 
quency is  at  least  .5  per  cent.  Dunfermline  has  more  careful 
work  than  any  public  school  system  in  this  country,  probably, 
but  its  examination  system  is  so  arranged  that  all  pupils  are 
not  examined  each  year.  If  the  whole  school  system  were 
covered  each  year  by  thorough  examinations,  the  percentage 
would  probably  be  raised.  For  serious  cases,  the  percentage 
is  probably  less  than  .2.  It  can  be  seen  from  this  that  many 


AILMENTS   OF  SCHOOL  CHILDREN       179 

cities  have  not  found  the  cases.  When  the  attention  of  medi- 
cal men  and  nurses  is  drawn  to  the  importance  of  this  ail- 
ment and  its  prevention,  the  figures  will  very  rapidly 
climb  up. 

14.  PALATE  DEFECT,  CLEFT  PALATE,  ETC. 

Cleft  palate  is  associated  with  hare  lip.  The  high,  nar- 
row palate  is  associated  with  enlarged  tonsils  and  adenoids. 
Fortunately,  the  ailment  is  uncommon,  only  seven  cities 
mentioning  it,  and  three  of  this  number  with  only  one  case. 
It  might  be  placed  with  the  Orthopedic  defects,  or  "De- 
formities." The  percentage  for  Cambridge  is  .05 ;  for 
Rochester,  1.7;  and  for  Newark,  1.7.  It  is  not  mentioned 
in  either  Boston  report.  The  average  proportion  is  probably 
seven  cases  in  a  thousand. 

15.   SKELETON  DEFECTS,  ORTHOPEDIC,  DEFORMITIES. 

Spinal  curvature  (scoliosis),  round  shoulders,  and  the 
like,  are  given  separate  space  in  the  next  two  columns  (89 
and  90),  because  of  their  importance  in  school  life.  In  cer- 
tain cases  spinal  curvature  was  given  with  other  deformities 
and  is  here  included.  They  should  be  kept  separate.  Pigeon 
breast,  caused,  like  scoliosis,  quite  largely  by  rickets  in  in- 
fancy, wryneck,  webbed  fingers  and  toes,  flat  feet,  and  a 
number  of  others  come  in  this  list. 

The  frequency  is  about  .2  per  cent,  or  less. 

In  the  case  of  this  and  the  following  group  of  ailments 
we  have  the  province  of  medical  gymnastics,  or  therapeutic 
exercises.  In  the  School  Clinic  at  Dunfermline,  previously 
mentioned,  there  is  a  separate  division  with  an  expert  in 
charge  for  all  such  work.  Through  massage,  carefully 
guided  exercises,  and  general  hygienic  regimen  much  which 
cannot  be  surgically  or  medically  cured,  can  be  helped,  and 
improved. 

1 6.  SPINAL  CURVATURE,  POSTURE,  ROUND  SHOULDERS,  FLAT 

CHEST 

The  lack  of  sufficient  medical  examiners  and  the  peculiar- 
ities of  public  opinion,  or  public  sentiment,  are  such  that 


i8o    SCHOOL  HEALTH  ADMINISTRATION 

genuine,  all-round  physical  examinations  are  not  yet  being 
made  in  American  public  schools.  To  discover  and  study 
such  defects  as  are  here  listed  means  the  removal  of  the 
child's  clothing,  or  at  least  stripping  to  the  waist.  This  is 
now  practiced  in  the  best  private  and  normal  schools,  and 
colleges.  A  very  few  cities  are  introducing  such  examina- 
tions in  the  high  schools;  and  some  courageous  medical  ex- 
aminers go  ahead  and  do  their  work  in  a  thorough  way  in 
the  elementary  schools.  In  certain  or  all  cities  there  are 
school  districts  in  which  anything  necessary  for  scientific 
work  can  be  done,  and  in  others,  generally  the  richer  and 
supposedly  more  enlightened,  the  policy  is  more  that  of 
"hands  off."  Yet  the  children  of  the  latter  are  frequently 
the  ones  who  need  most  attention  of  this  kind. 

The  frequency  in  the  elementary  school  population  is  per- 
haps not  far  from  .8  per  cent,  and  perhaps  one  per  cent. 

Dunfermline  has  2.2  per  cent  well  marked  cases  of  spinal 
curvature  (97  cases  and  4,492  pupils  examined).  Evidently 
here  there  were  adequate  examinations,  slight  deviations  re- 
garded perhaps,  and  a  greater  prevalence  than  in  this  coun- 
try; although  we  may  have  more  cases  than  even  one  per 
cent. 

Fundamental  prevention  of  this  ailment  must  begin  in 
the  child's  infancy  through  the  preventing  of  rickets  and 
such  ailments. 

17.   SPEECH  DEFECTS,   STUTTERING,   STAMMERING,   LISPING, 

LALLING 

Stammering  or  stuttering  is  the  commonest  of  these  ail- 
ments. "The  condition  is  commonly  the  result  of  imitation, 
and  this  gives  rise  to  a  difficulty  in  treatment,  because  stam- 
merers are  likely  to  increase  each  other's  defects  when  placed 
in  special  classes."  These  words  by  Dr.  Cruikshank  may 
be  too  strong  against  class  treatment;  for  pupils  imitate  and 
start  the  habit  only  when  they  think  it  is  smart,  but  when 
there  is  a  good  deal  of  social  disapproval  or  stigma  upon  it, 
the  danger  of  imitation  seems  to  be  slight.  The  new  book 
by  Professor  Scripture  on  "Stuttering  and  Lisping"  marks 


AILMENTS  OF  SCHOOL  CHILDREN       181 

an  epoch  in  the  scientific  diagnosis,  treatment  and  prevention 
of  this  distressing  ailment. 

Only  433  cases  were  reported  by  the  physicians  in  all  the 
cities. 

In  Newark,  the  percentage  of  such  cases  among  the 
children  examined  is  nearly  1.7.  In  Dunfermline,  the  per- 
centage is  about  the  same.  Exceedingly  few  cases  are  men- 
tioned in  the  24  other  cities  outside  of  Newark.  Probably 
less  than  one  per  cent  are  affected  the  country  over.  We 
place  it  .9  per  cent,  to  give  it  definiteness. 

This  concludes  physical  defects  according  to  our  classi- 
fication. A  later  table  will  show  the  percentages  for  all 
the  ailments,  and  the  probable  number  of  cases  among  the 
elementary  school  children  in  all  the  cities  taken  together, 
and  comparing  them  with  the  cases  actually  reported. 

There  are  undoubtedly  very  interesting  and  important 
individual  variations  among  the  cities  in  the  number  of  cases 
of  the  various  ailments  actually  existent;  but  the  personali- 
ties, standards,  equipments,  and  methods  of  the  workers 
in  the  school  health  service  are  at  present  so  varied  that 
the  real  health  variations  can  hardly  be  disclosed.  This 
remains  for  the  future.  Summit,  Winchester,  Montclair 
and  other  cities  of  a  suburban  character  should  show  very 
different  findings  from  Lowell,  Hoboken,  Jersey  City 
New  Bedford  and  foreign  factory  cities  generally.  Such 
sociological  differences  do  not  as  yet  appear. 


CHAPTER   SEVEN. 
COMMON  NON-INFECTIOUS  AILMENTS 

B.  Common  Non-Infectious  Ailments 

I.   ABSCESS,  BOILS,   ETC. 

This  class  of  ailments  is  very  infrequent  and  perhaps 
should  be  placed  with  wounds,  sores,  etc.  If  properly  cared 
for  by  the  nurse,  boils,  carbuncles  and  other  similar  infec- 
tions may  easily  be  classed  with  the  other  first-aid  treat- 
ments. Separate  place  is  given  here  because  it  is  mentioned 
separately  so  many  times  in  the  reports  of  12  cities.  All 
persons  who  have  had  these  troubles  can  sympathize  with 
the  children  and  realize  that  their  lives  can  be  filled  very 
full  of  suffering  from  such  infections.  The  percentage  of 
cases  is  very  low,  probably  near  .2  per  cent.  Boston  reports 
314  cases,  or  .5  per  cent  of  the  elementary  school  enroll- 
ment. 

2.   ACUTE   SORE  THROAT 

Sore  throat  is  quite  common  among  children  and  as  a 
term  is  better  than  more  technical  ones.  Perhaps  both 
laryngitis  and  pharyngitis,  mentioned  practically  only  by 
board  of  health  physicians,  could  also  be  included  in  this 
term,  although,  in  general,  accuracy  of  diagnosis  and  de- 
tailed statement  mean  more  scientific  procedure. 

Sore  throats  are  so  closely  associated  with  a  number  of 
infectious  diseases  that  in  some  towns,  such  as  Montclair, 
the  nurse  makes  a  practice  of  taking  a  swab  from  the 
throat  of  almost  every  child  severely  affected.  The  child 
is  first  temporarily  excluded;  the  nurse  goes  to  the  home 
with  the  child,  takes  the  swab,  and  instructs  the  mother 
in  the  care  of  the  child.  When  the  culture  has  been  made 
at  the  drug  store  or  Board  of  Health  office,  the  nurse  knows 
whether  the  child  should  be  excluded  and  turned  over  to 

182 


NON-COMMUNICABLE    AILMENTS       183 

the  Health  Department  as  a  diphtheria  or  other  case.  Noth- 
ing less  than  this  procedure  seems  to  be  sufficient  to  exclude 
incipient  stages  of  several  ailments  which  may  easily  become 
centers  of  infection,  out  of  school  if  not  within.  (The 
researches  of  Dr.  Chapin  at  Providence  make  it  doubtful 
whether  there  is  very  much  spread  of  infection  at  school, 
1911  report.)*  The  frequency  of  the  ailment  will  prob- 
ably vary,  as  will  most  of  the  ailments  in  this  class,  more 
than  the  physical  defects,  which  seem  to  be  remarkably 
constant,  depending  more  upon  the  weather,  home  and 
school  ventilation,  and  the  like. 

The  percentage  of  cases  during  the  school  year  is  prob- 
ably near  .2.  Boston  has  .5  and  Newark  .05  per  cent. 

3.    BRONCHITIS 

This  ailment  is  quite  infrequently  reported  or  found. 
Less  than  half  of  the  cities  mention  it.  Generally  the  case 
is  not  found  in  school,  and  is  only  reported  after  the  child 
has  returned.  It  seems  certain  that  an  adequate  and  sci- 
entific administration  of  this  work  will,  by  the  way,  neces- 
sitate fairly  complete  health  histories  of  the  children  in 
school  and  out.  The  child  who  is  absent  with  bronchitis, 
for  example,  should  be  visited  by  the  nurse  and  inspected 
on  his  return  and  a  record  of  the  ailment  made.  Common 
ailments  are  now  much  neglected.  If  the  school  medical 
service  is  ever  to  develop  into  what  it  should  become,  a 
preventive  as  well  as  a  curative  agency,  the  causes  as  well 
as  the  cases  of  all  these  common  ailments  which  so  much 
lower  the  vital  efficiency  of  children  will  be  matters  of 
careful  study. 

The  frequency  of  bronchitis  is  as  follows:  Boston,  say, 
300  cases  (for  the  nurses  undoubtedly  found  a  number  of 
new  cases),  .5  per  cent;  Lowell,  .2  per  cent;  Trenton,  .1 
per  cent,  and  the  others  less. 

The  frequency  is  at  least  .1   per  cent. 


*See  also  Professor  Jordan's  article  in  the   1912  N.   E.  A.  report 
on  School  Diseases. 


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NON-COMMUNICABLE  AILMENTS        187 

4.   CLEANLINESS  NEEDED 

The  great  enemy  of  health  is  filth,  and,  along  with  fresh 
air,  exercise,  and  nourishing  food,  cleanliness  constitutes 
one  of  the  great  preventive  methods.  Dr.  Cruickshank, 
in  his  1911-12  Dunfermline  report  previously  mentioned, 
adequately  sums  up  the  matter  (page  109)  in  these  words: 

"On  looking  through  the  report  one  cannot  help  being 
impressed  by  the  number  of  children  suffering  from  dis- 
eases which  ought  to  be — which  indeed  are  preventable. 
And  when  we  analyze  the  causes  of  the  various  diseases 
and  defects  and  seek  some  common  factor  operating  in 
every  case  we  find  it  in  the  environment.  But  environment 
itself  is  so  complex  that  we  must  seek  for  some  common 
factors  in  it  which  specially  influence  the  health  of  tender 
child  life.  Of  these  factors  there  are  several,  but  the  most 
important  are  dirt  and  foul  air.  Lack  of  cleanliness,  per- 
sonal and  otherwise,  and  absence  of  fresh  air,  are  probably 
accountable  for  more  diseases  than  all  other  factors  to- 
gether. Frequently  they  are  the  direct  cause,  as  in  certain 
inflammations  of  the  eyes  and  skin,  frequently  the  indirect 
cause,  as  in  many  cases  of  malnutrition  and  tuberculosis." 

The  schools  must  fight  filth  as  the  arch-fiend. 

The  details  regarding  school  baths,  compulsory  and  en- 
ticed cleaning,  and  the  like  will  be  set  forth  later. 

Some  of  the  cities  do  not  mention  this  condition  or  ail- 
ment; Boston  mentions  it  in  neither  the  health  nor  the  school 
department  reports.  None  of  the  cities  are  equipped  at 
the  schools  for  providing  adequate  school  cleaning,  and  it 
is  a  waste  of  energy  to  tell  a  child  to  bathe  at  home  when 
there  is  no  bathtub  there  and  his  parents  have  never  prac- 
ticed this  element  of  civilization,  frequent  bathing.  Shower 
baths  and  swimming  pools  are  essential  to  the  cleanliness 
of  the  child  population.  Rigid  treatment  will  in  most  cases 
procure  for  the  children  clean  underclothing  and  other  gar- 
ments, and  the  teacher  can  look  out  for  faces  and  hands. 
Some  persons  advocate  hot  and  cold  water  wall-washbowls 
in  each  class  room  not  only  for  the  purpose  of  affording 
drinking  water  by  means  of  a  sanitary  drinking  fountain 


1 88     SCHOOL  HEALTH  ADMINISTRATION 

and  water  for  drawing  work  and  cleaning  the  blackboards 
and  watering  flowers,  but  also  to  help  develop  the  personal 
cleanliness  habit. 

Great  tact  and  care  is,  of  course,  required  of  the  school 
nurse  and  teachers,  but  the  matter  can  hardly  be  overem- 
phasized from  the  health  standpoint. 

Some  of  the  frequencies  for  uncleanliness  are  as  follows : 
Summit,  2  per  cent;  Norwood,  1.3  per  cent;  Winchester, 
.5  per  cent;  Montclair  (estimate,  35  cases),  i  per  cent; 
Yonkers,  .3  per  cent;  New  Bedford,  .2  per  cent;  Provi- 
dence, .3  per  cent;  Jersey  City,  .2  per  cent;  Newark  (45 
cases),  .2  per  cent.  This  is  an  average  percentage  of  .6. 

Considering  the  fact  that  many  cases  are  not  recorded, 
and  that  in  some  of  these  cities,  such  as  Providence,  the  in- 
spection covered  only  a  part  of,  or  very  inadequately,  the 
elementary  school  population,  and  that  these  figures  where 
there  were  no  examinations  are  based  upon  enrollment  and 
not  average  attendance,  we  should  probably  find  that  at  any 
one  time  from  one  to  two  per  cent  (say  one)  were  in  need 
of  Immediate  cleaning  (bathing  and  clean  clothes,  not  to 
mention  vermin)  in  order  to  make  them  sanitarily  whole- 
some members  of  a  classroom.  The  physician  in  Summit, 
in  a  first-class  suburban  city,  found  a  higher  percentage  of 
cases,  I  believe,  because  he  was  more  sensitive  to  this  condi- 
tion, took  a  more  energetic  attitude  toward  the  treatment 
of  such  cases,  or  kept  better  records  of  the  work  done.  The 
physician  who  is  director  of  hygiene  at  Cambridge  has  de- 
vised a  nozzle  for  a  hose  by  which  he  washes  down  ten  to 
fifteen  boys  at  a  time  to  their  and  their  teachers'  delight. 

We  give  below  the  summaries  of  two  of  the  four  tables 
on  Cleanliness  given  in  the  1911-12  report  of  Dunferm- 
line,  Scotland : 

Number  of  children  examined,  ages  4  to  14  and  over, 
999  boys  and  828  girls. 

Per  cent.  Per  cent. 

Boys.  Girls. 

Cleanliness,  "Good.     Above  average  percentage." 58.15  69.41 

Cleanliness,  "Medium.    Average  percentage." 37-73  29.35 

Cleanliness,  "Bad.     Below  average  percentage." 4.10  1.23 


NON-COMMUNICABLE  AILMENTS        189 

The  girls  are  cleaner  than  the  boys,  although,  as  shown 
in  other  tables,  with  their  long  hair  they  suffer  more  from 
pediculosis  which  may  also  be  looked  upon  as  uncleanliness. 

Other  tables  show  that  boys  are  very  much  dirtier  at 
the  age  of  eleven,  than  at  any  age  before,  while  girls  grow 
cleaner. 

Percentage  of  children  marked  "bad"  as  to  cleanliness  in 
Dunfermline,  Scotland,  1911-12.  Children  examined,  999. 

Per  cent.  Per  cent. 

Boys.  Girls. 

Infants  examined  for  first  time,  average  age,  6  years.  ..  .1.62  1.22 

Examined  entering  Senior  School,  average  age,  8  years... 3.1  1.23 

Third   examination,    1 1   years    5.55  i.oi 

Fourth  examination,  leaving  school,   14  years 1.51  .... 

The  director  of  hygiene  points  out  the  fact,  too,  that 
parents,  on  receiving  the  notice  of,  and  the  invitation  to 
the  examination  of  their  children  get  them  in  clean  condition 
for  it.  "Parents  receive  notice  of  the  intending  examina- 
tion, and  frequently  prepare  the  children  for  it.  The  figures 
returned  from  the  School  Medical  Officer's  examination 
will  therefore  always  show  a  condition  of  things  better  than 
actually  exists"  (page  30). 

If  physicians  and  nurses  in  this  country  tabulated  their 
findings  and  made  as  careful  studies  of  their  children  as 
these  figures  indicate  it  is  very  probable  that  our  larger 
estimate  of  two  per  cent  of  all  elementary  school  children 
would  not  be  too  large. 

5.    CATARRH,    CHRONIC    RHINITIS,    COLUMNS     103-4 

Chronic  bad  cold  and  "running  nose,"  resulting  from 
sitting  in  school  with  wet  feet,  bad  ventilation  at  school  or 
home,  or  some  other  single  or  combination  of  causes,  is  a 
more  serious  and  common  ailment  than  is  generally  realized. 
Most  of  the  cities  that  have  much  to  report  at  all  regarding 
the  health  conditions  of  the  children  in  general,  and  not 
merely  from  one  particular  aspect,  say  infection,  report 
some  cases.  The  number  of  cases  found  will  depend  upon 
the  time  of  year  the  examination  or  the  inspections  take 


190    SCHOOL  HEALTH  ADMINISTRATION 

place  since  many  cases  may  remain  undetected  until  bad 
weather  or  other  untoward  conditions  bring  them  out. 

The  Dunfermline  report  previously  mentioned  has  this 
to  say  regarding  catarrhal  conditions  in  connection  with 
adenoids :  "Adenoids  are  clearly  associated  with  catarrhal 
conditions  of  the  naso-pharnyx.  As  these  conditions  are  so 
very  prevalent  we  must  continue  to  expect  large  numbers 
of  children  to  suffer  from  this  disagreeable  and  harmful 
condition.  It  is  quite  probable,  however,  that  pure  air  in 
the  schools,  instruction  in  the  use  of  the  handkerchief,  and, 
when  adenoids  are  suspected,  the  daily  practice  of  nasal 
respiratory  exercises,  would  reduce  the  frequency  of  opera- 
tion for  this  condition  to  a  minimum"  (page  35). 

Some  of  the  frequencies  are  as  follows:  Trenton,  2 
per  cent;  Summit,  7  per  cent;  Hoboken,  only  3  cases  re- 
corded; Rochester,  with  over  15,000  pupils  examined, 
records  no  case;  Yonkers,  i  per  cent;  Cambridge,  2  per 
cent;  Newark  records  no  cases  and  no  other  ailment  whicfy 
seems  to  cover  this  condition  unless  it  could  be  placed  with 
adenoids,  which  is  unlikely;  Boston  (327  cases),  .5  per  cent. 
Here  we  have  an  average  for  the  cities  mentioning  the 
most  cases  an  average  percentage  of  .7.  The  frequency 
must  be  almost  that  of  cleanliness,  one  or  two  per  cent,  say 
one  per  cent.  How  many  cases  the  various  cities  missed, 
judging  that  the  actual  variations  as  among  cities  is  not 
great,  can  be  seen  by  comparing  the  figures  given,  reduced 
to  percentages,  with  this  standard.  Boards  of  Health,  as 
with  most  other  diseases,  have  a  bad  showing. 

6.    BAD    COLDS,    CORYZA,    COLUMNS    105-106 

In  this  list  are  those  severe,  comparatively  non-infectious 
colds  which  are  so  frequent  among  children  and  which  en- 
tail such  severe  consequences.  Probably  all  colds  are  more 
or  less  infectious.  Hoag,  in  his  "Health  Index  of  Chil- 
dren," page  50,  says  they  are  the  most  infectious  of  all 
ailments:  "Colds  are  probably  about  the  most  contagious 
form  of  disease  we  have,  yet  many,  if  not  most  people  still 


NON-COMMUNICABLE  AILMENTS        191 

go  on  regarding  them  as  due  to  drafts,  getting  wet,  to  'night 
air'  and  similar  delusions.  As  a  matter  of  fact  anything 
which  is  capable  of  reducing  our  resistance  makes  it  easy 
for  cold  germs  to  gain  the  ascendancy,  but  the  cold  is  di- 
rectly due  to  the  germ  or  germs,  and  these  causes  should 
not  be  confused  with  the  predisposing  factors." 

Since  ua  cold  can  always  be  laid  to  someone  else,"  as 
seems  probable,  it  should,  perhaps,  be  treated  as  an  in- 
fectious disease  of  the  minor  group,  instead  of  in  this  place. 
We  give  place  here  for  it,  because  no  city  of  which  I  know 
places  it  in  the  infectious  group.  I  leave  place  for  it  also, 
however,  along  with  influenza  and  grippe.  The  future  will 
probably  bring  about  a  handling  of  "bad  colds"  the  same 
as  other  infectious  ailments. 

Nurses  mention  this  ailment  in  but  four  cities  and  the 
physicians  in  but  one.  Both  the  health  and  the  school  de- 
partments record  it  as  Coryza  in  Boston.  The  frequencies 
are  as  follows:  Norwood  (50  cases),  3.2  per  cent;  Win- 
chester (33  cases),  2.2  per  cent;  Montclair  (108  cases), 
3.3  per  cent;  Boston  (400  cases),  .7  per  cent. 

The  average  percentage  of  elementary  children  is,  there- 
fore, 2.7  per  cent.  Undoubtedly,  the  ailment  occurred  with 
the  same  or  greater  frequency  in  all  cities  but  was  not  re- 
corded. The  inadequate  medical  staffs  found  that  they  had 
far  more  than  they  could  do  with  the  most  serious  and  even 
death-dealing  diseases,  to  pay  any  attention  to  these  minor 
ones  which  so  frequently  bring  on  the  greater.  If  we  are 
going  to  make  medical  supervision  what  it  should  be,  a 
means  of  scientific  prevention  as  well  as  cure,  however,  these 
cases  of  coryza  or  bad  cold  will  receive  attention  and  study. 

Our  estimate  of  this  ailment,  counting  only  cases  which 
should  probably  be  out  of  school,  or  at  least  receiving  care- 
ful treatment,  is  at  the  lowest,  three  per  cent.  It  is  probably 
not  less  frequent  in  high  school.  Rather  infrequent  inspec- 
tion at  the  Montclair  high  school  seems  to  show  this. 

These  are  regarded  as  separate  and  distinct  cases,  al- 
though we  have  here  an  ailment  which  may  come  upon  a 


192     SCHOOL  HEALTH  ADMINISTRATION 

child  more  than  once  in  a  school  year.  Perhaps,  too,  not 
less  than  three  per  cent  of  the  school  children  are  affected 
with  bad  colds  at  some  time  in  the  year.  Those  experi- 
enced in  the  classroom  would  probably  place  the  estimate 
very  much  higher. 

7.    EAR    DISCHARGE,    OTITIS    MEDIA,    RUNNING    EAR,    OTOR- 
RHEA,  COLUMNS   107-108 

Here  we  have  a  serious  ailment  closely  connected  with 
deafness  and  adenoids.  Starting  from  bad  colds  and  nasal 
catarrh,  along  with  adenoids  and  perhaps  enlarged  tonsils, 
we  get  an  inflammation  which  travels  up  the  eustachian 
tubes  and  sets  up  a  suppuration  in  the  middle  ear  which, 
breaking  through  the  ear  drum,  pours  out  along  the  channel 
of  the  outer  ear,  a  most  distressing  condition.  If  not  cared 
for  the  ailment  may  spread  into  the  mastoid  bone  back  of 
the  ear,  making  necessary  operations  for  mastoiditis. 

The  treatment  takes  a  long  time,  generally,  and  nothing 
short  of  a  first-class  school  clinic  will  meet  the  situation  for 
most  children.  Sixty-seven  cases  made  3,074  visits  to  the 
school  clinic  in  Dunfermline,  Scotland,  an  average  of  about 
46  visits  each,  and  probably  not  all  of  these  cases  were  cured 
at  the  time  of  reporting. 

A  medical  inspection  system  which  neglects  this  ailment 
is  either  derelict  in  its  duty,  or  very  far  short  of  what  the 
school  medical  service  should  be. 

Seven  cities  in  this  group  of  twenty-five  have  made  no 
record  of  such  cases,  either  by  nurses  or  physicians.  Jersey 
City  records  but  3  cases,  excluded.  About  how  many  cases 
there  actually  were  can  be  estimated  from  the  following 
percentages : 

Frequency  of  Ear  Discharge  among  elementary  pupils: 
Summit,  .6  per  cent;  Norwood,  .2  per  cent;  Winchester,  1.8 
per  cent  (27  cases);  Montclair,  .3  per  cent;  Schenectady, 
2.2  per  cent;  Waterbury,  .2  per  cent;  Yonkers,  .8  per  cent; 
New  Bedford  (lib  cases),  .9  per  cent;  Trenton  (among 
10,587  pupils  examined  only  7  cases)  ;  Cambridge  (69 
cases) ,  .4  per  cent ;  Providence,  .4  per  cent ;  Newark  ( 24,3 10 


NON-COMMUNICABLE  AILMENTS        193 

children  examined,  only  31  cases),  .1  per  cent;  Boston  (425 
cases,  counting  new  cases  found  by  nurses),  .7  per  cent. 
Average  percentage,  .7  per  cent. 

Among  1,8 1 2  children  ranging  in  age  from  four  to 
above  14,  in  Dunfermline,  there  were  37  cases  of  "purulent 
discharge,"  and  15  cases  of  "old  discharge,"  percentages  of 
2  and  .8.  This  percentage  of  2  seems  to  be  about  the  num- 
ber we  should  find  here  if  we  were  to  have  more  careful 
examinations  of  all  children.  This  will  vary  with  the  cities 
somewhat,  undoubtedly,  but,  I  feel  sure,  much  more  because 
of  the  differences  in  the  doctors  and  nurses.  Many  of  the 
cases,  moreover,  have  no  actual  discharge  at  all,  and  yet  are 
serious  enough  to  cause  partial  deafness. 

The  1910  report  of  the  Board  of  Education  of  England 
on  this  subject  (page  48)  gives  the  following  summary  of 
a  table  showing  the  relation  of  ear  discharge  to  defective 
hearing  and  adenoids  and  tonsils: 

Number  children  with  defective  hearing,  all  ages 441 

Proportion  of  these  cases  due  to: 

Middle  ear  disease  with  discharge H-O% 

Middle    ear    disease    without    discharge    generally    associated 

with  enlarged  tonsils  and   adenoids 65.7% 

Ceruminous  obstruction   (ear  wax) 20.1% 

99-8% 

According  to  this  report,  we  should  judge  that  about  80 
per  cent  of  deafness  comes  from  this  ailment.  We  found 
that  the  probable  proportion  of  defective  hearing  was  about 
one  per  cent.  This  would  show  that  middle  ear  disease  was 
more  frequent  than  one  per  cent.  We  do  not  have  recorded 
here  the  number  of  cases  with  no  associated  defective 
hearing. 

In  the  1911  report  of  the  same  health  officer  (Sir  Geo. 
Newman,  London)  we  have  another  summary  of  several 
tables,  page  44,  which  throws  more  light  on  this  ailment. 
It  is  a  report  of  the  causes  of  deafness  found  among  1,265 
children  aged  five,  and  1,352  aged  12  examined,  2,617 
altogether: 


i94    SCHOOL  HEALTH  ADMINISTRATION 

CAUSES  OF  DEAFNESS.    2617  PUPILS 

Per  cent.  Per  cent. 

Ages.  Age  12. 

Due  to  adenoids 78.4  52.0 

Due  to  suppurative  otitis  media  (ear  discharge) 15.6  38.0 

Due  to  suppurative  otitis  media  and  adenoids 5.8  10.0 


99.8  100 

This  shows  a  slightly  different  emphasis,  showing  per- 
haps that  back  of  it  all  are  the  adenoids.  Since  adenoids 
are  probably  enlarged  through  neglected  colds  almost  en- 
tirely, we  see  here  a  serious  chain  of  factors  which  must  not 
be  overlooked  by  the  school  medical  service. 

In  summary,  we  should  say  that  this  is  a  very  serious 
ailment,  somewhat  difficult  of  diagnosis,  very  hard  to  cure, 
and  taking  a  long  time,  and  existent  among  from  one  to  two, 
say  1.5  per  cent  of  elementary  school  children,  more  in  the 
the  lower  grades  than  in  the  higher.  This  is  practically 
Cornell's  estimate  given  in  his  book,  page  589. 

8.    EARS,    MINOR    AILMENTS,    IMPACTED   CERUMEN    OR    EAR 
WAX,  EAR  ACHES  DUE  TO  SEVERAL  CAUSES,  BUT  FRE- 
QUENTLY TREATED  BY  THE  NURSES,  FOREIGN 
BODIES   IN  THE   EAR,    ETC. 

We  have  maneuvered  our  nomenclature  to  bring  otitis 
media  and  the  other  ear  ailments  together.  These  other 
ailments  are  minor  but  important.  We  have  seen  the  influ- 
ence impacted  ear  wax  has  on  hearing,  producing  over  20 
per  cent  of  the  cases  according  to  the  investigator  quoted, 
and  the  persistent  earache,  foreign  bodies  and  small  boils, 
and  the  like  are  no  small  part  of  a  child's  life,  meaning,  if 
nothing  worse,  absence  from  school  or  poor  attention  in  it 
in  many  cases.  Most  of  the  cases  are  cases  of  impacted 
cerumen,  although  the  Boston  nurses  reported  222  cases  of 
eczema  of  the  ear  to  229  cases  of  cerumen  and  40  of  foreign 
bodies.  The  eczema  and  boils  frequently  come  from  scratch- 
ing due  to  pediculosis  and  dirt,  and  consequent  infection. 

Only  six  cities  mention  these  smaller  ailments  of  the  ears. 
Winchester  mentions  only  two  cases ;  Yonkers  (say  80  cases) , 


NON-COMMUNICABLE  AILMENTS        195 

.6  per  cent;  Cambridge,  .4  per  cent;  Lowell,  .3  per  cent; 
Providence,  12  cases  only;  Boston  (229  cases,  eczema  cases 
put  with  eczema),  .3  per  cent.  The  average  is  .4  per  cent. 
These  cities  did  not  have  physical  examinations,  so  we  may 
understand  that  only  a  part  of  the  cases  among  the  entire 
enrolled  elementary  school  population  were  found.  Half  a 
per  cent  (.5  per  cent)  seems  reasonable  for  these  minor 
ailments.  Careful  records  of  the  whole  health  history  of 
children  will  probably  increase  this  percentage.  We  notice 
as  we  go  along  that  those  cities  having  the  names  of  these 
ailments  printed  on  the  report  forms  get  records  of  such 
cases,  while  those  that  have  a  few  names  of  ailments  which 
are  very  uncommonly  met,  e.  g.,  tuberculosis,  do  not  get 
them.  The  medical  officers  do  not  look  for  the  ailment,  or 
else  fail  to  write  it  in. 

9.   ECZEMA 

"Eczema  is  a  non-contagious  inflammation  of  the  skin 
caused  principally,  or  altogether,  by  disturbance  in  nutri- 
tion" (Cornell).  There  are  many  varieties,  and  many  skin 
ailments  are  called  by  this  name  which  are  not  true  eczema. 
The  ailment  is  handled  chiefly  by  the  nurses,  and  cared  for 
by  them,  either  in  giving  treatments  or  in  showing  mothers 
how  to  give  them.  In  Newark,  only  the  nurses  mention  this 
ailment,  but  they  record  9,857  cases  as  treated.  Whether 
this  represents  so  many  children  we  cannot  say. 

Frequencies:  Summit,  .9  per  cent;  Norwood,  .5  per 
cent;  Montclair  (55  cases),  1.4  per  cent;  Waterbury,  .3 
per  cent;  Yonkers,  .8  per  cent;  New  Bedford,  .2  per  cent; 
Trenton,  .3  per  cent;  Cambridge,  .2  per  cent;  Lowell,  .1 
per  cent;  Providence,  .4  per  cent;  Newark,  45  per  cent;* 
Boston  (1,000  cases),  1.6  per  cent  (on  61,000  inspections), 
i  per  cent  on  100,000  inspections. 


*A  most  astounding  percentage,  and  probably  meaning  cases,  with 
several  cases  to  a  child  than  that  not  far  from  half  of  the  children 
examined  had  the  ailment.  The  percentage  would  be  also  decreased  by 
half  when  we  consider  that  the  nurses  covered  all  the  elementary  school 
population,  in  a  way,  while  the  examination  reached  only  about  half. 
Leaving  this  at  15  per  cent  would  be  very  far  beyond  other  cities. 


196    SCHOOL  HEALTH  ADMINISTRATION 

The  average  percentage,  excluding  Newark,  is  .6  per 
cent.  The  actual  number  of  cases  does  not  probably  exceed 
one  per  cent.  Let  us  say  .7  per  cent. 

IO.  EYES,  MINOR  AILMENTS.  SORE  EYES,  BLEPHARITIS,  STYES, 
IRITIS,   CORNEAL  ULCER,  KERATITIS,   FOREIGN 
BODIES  IN  THE  EYE 

Here  we  have  a  host  of  comparatively  minor  and  yet 
serious  cases  of  eye  ailments,  mostly  of  the  external  eye. 
Some  or  most  of  these  can  be  obviated,  perhaps,  by  proper 
glasses,  thus  avoiding  eyestrain  and  lowered  resistance.  We 
do  not  include  here  conjunctivitis  of  any  kind  nor  trachoma, 
since  they  properly  belong  in  the  infectious  group,  and  must 
receive  different  treatment.  Blepharitis,  or  common  sore 
eyes,  is  found  more  frequently  than  any  other  in  the  group, 
with  styes  a  close  second. 

The  frequencies  are  greater  than  for  any  ailment  found 
for  some  time,  and  the  column  showing  the  nurses'  cases  is 
well  filled,  showing  that  the  nurses  have  handled  a  good 
many  of  them,  and  probably  found  many  new  cases  not 
found  by  the  doctors. 

Percentages  of  elementary  school  population  or  of  num- 
ber of  children  examined:  Summit,  2.3  per  cent;  South 
Manchester,  .7  per  cent;  Norwood,  only  two  cases;  Win- 
chester (16  cases),  i  per  cent;  West  Orange,  no  cases; 
Montclair  (26  cases),  .8  per  cent;  Hoboken  (53  cases), 
.6  per  cent;  Waterbury,  .4  per  cent;  Yonkers  (234  cases), 
.2  per  cent;  Trenton,  .3  per  cent;  Cambridge  (54  cases), 
.4  per  cent;  Lowell,  1.7  per  cent;  New  Haven,  .7  per  cent; 
Rochester,  .3  per  cent;  Providence  (203  cases),  .7  per  cent; 
Jersey  City  recorded  only  excluded  cases;  Newark,  .7  per 
cent;  Boston  (1,116  cases),  1.8  per  cent. 

The  average  percentage  is  .8  per  cent. 

We  get  our  surprises  here  from  the  cities  that  are  sup- 
posed to  have  physical  examinations,  much  more  careful  than 
inspections,  but  the  examination  cities  excepting  Summit  do 
not  show  up  well  in  this  case.  Some  of  the  cities  report  no 


NON-COMMUNICABLE  AILMENTS         197 

cases  and  these  are  either  board  of  health  cities  or  other  cities 
starting  the  work  and  not  yet  well  established. 

We  should  not  expect  Summit  to  have  the  largest  pro- 
portion of  cases,  since  its  environment  is  very  good  and 
there  is  but  a  small  foreign  (Italian)  section.  We  should 
expect  these  ailments  in  the  mill  and  factory  towns  such  as 
Hoboken,  Jersey  City,  Lowell,  New  Bedford,  Providence 
and  Newark.  The  cases  were  probably  there  but  were  not 
found. 

The  same  conservative  judgment  hitherto  exercised 
would  lead  us  to  estimate  these  ailments  as  existing  in  at  least 
1.5  per  cent  of  the  elementary  children  at  some  time  during 
the  school  year,  and  that  the  percentage  of  cases  would  be 
about  two  per  cent. 

II.  HEADACHE,  NEURALGIA  AND  MIGRAINE 

These  are  symptoms,  of  course,  but  they  must  be  treated 
as  ailments  by  the  nurses  and  often  by  the  physicians  because 
of  inability  or  lack  of  necessity  of  giving  a  thorough  diag- 
nosis. The  eyes  may  be  tested,  the  teeth  examined,  and  the 
nurse  can  have  a  talk  with  the  mother  about  the  child's  diges- 
tion and  food,  but  even  then  the  cause  may  be  untouched. 

Strangely,  the  physicians  report  the  ailment  more  than 
do  the  nurses,  the  latter  in  only  three  cities  mentioning  it. 
Some  of  the  frequencies  are  as  follows:  Summit,  1.4  per 
cent;  Winchester,  2  per  cent;  Montclair,  1.3  per  cent;  com- 
paratively few  cases  in  the  following  cities  :Newark,  .8  per 
cent;  Boston,  .4  per  cent. 

The  average  is  about  1.3  per  cent. 

For  various  reasons,  we  judge  this  proportion  to  be 
actually  about  1.5  per  cent  to  2  per  cent,  say,  at  least,  1.5 
per  cent.  Dr.  Hoag  reports  very  much  higher  percentages 
among  the  rural  schools  of  Minnesota,  but  his  data  are  ex- 
tremely poor,  resulting  from  questioning  pupils. 

12.  LARYNGITIS 

Only  five  cities  record  over  one  case  of  this  ailment. 
In  Winchester,  the  frequency  is  1.4  per  cent;  in  Mont- 


198     SCHOOL  HEALTH  ADMINISTRATION 

clair,  .3  per  cent;  Cambridge,  .1  per  cent;  Providence,  .07 
per  cent;  Boston,  .25  per  cent. 

The  average  for  these  cities  is  .4  per  cent. 

The  ailment  is  so  bound  up  with  colds,  sore  throat  and 
the  like,  that  it  is  bound  to  be  very  variable,  perhaps.  Never- 
theless, both  departments  at  Boston  and  a  number  of  other 
cities  give  it  separate  record,  and  this  is  probably  best.  We 
leave  it  with  an  estimate  of  five  in  a  thousand. 

13.  NOSE-BLEED,  EPISTAXIS. 

Children  frequently  have  nose-bleed  and  do  not  know 
how  to  stop  it,  using  various  nostrums  and  superstitious 
charms  instead  of  effective  means  for  stopping  the  enervating 
bleeding. 

The  nurses  in  Boston  found  136  cases,  a  percentage  of 
less  than  .2  per  cent.  Perhaps  the  general  proportion  would 
stand  near  this  number,  .2  per  cent. 

14.    PHARYNGITIS,  CHRONIC  SORE  THROAT,  COLUMNS   1 2 1-2 

We  get  our  principal  notice  of  this  ailment,  also,  by  both 
departments  at  Boston.  Only  three  other  cities  mention  it, 
yet  it  is  a  fairly  common  ailment  of  childhood. 

Montclair  had  12  cases  reported,  a  percentage  of  .3  per 
cent;  Trenton,  .2  per  cent;  Boston  (175  cases,  counting  some 
new  ones  found  by  the  nurses),  .3  per  cent,  or  less. 

With  little  further  study,  we  leave  the  estimate  for  future 
investigations  to  correct  at  .3  per  cent — the  ratio  of  cases 
found  to  the  elementary  school  population  when  all  children 
are  carefully  inspected  and  examined. 

15.    RHEUMATISM  AND  "GROWING  PAINS" 

Rheumatism  is  very  serious  because  of  its  effect  upon  the 
heart,  and  the  so-called  "growing  pains"  should  be  carefully 
looked  into.  The  ailment  is  fortunately  not  common.  Only 
three  cities  mention  it.  The  frequencies  are  also  very  low. 
One  case  in  a  thousand  would  probably  be  above  the  mark. 
Closer  examinations  will  probably  show,  however,  that  .1 
per  cent  is  not  an  overestimate  of  the  actual  number*  of  cases 
among  elementary  school  children. 


NON-COMMUNICABLE  AILMENTS         199 

Every  case  should  be  carefully  studied  with  a  view  to 
cure  and  prevention.  Heart  disease  probably  arises  in  most 
cases  from  an  attack  of  rheumatism  in  childhood;  and  this 
is  one  of  the  greatest  death-dealing  diseases,  standing  only 
lower  than  tuberculosis.  "It  is  impossible  to  cure  organic 
heart  disease,  but  the  study  of  its  prevention  becomes  one 
of  the  most  important  functions  of  the  school  medical  serv- 
ice."— Cruickshank. 

I  6.  SEX  AILMENTS  AND  HABITS 

Very  few  ailments  of  this  character  are  mentioned, 
largely  because  of  the  lack  of  searching  examinations  and 
careful  following-up  of  cases.  Some  nurses  have  done  splen- 
did work  in  this  field  of  sex  education,  cure  and  prevention. 
Some  of  the  ailments  mentioned  are :  Montclair,  2  cases  of 
masturbation  and  one  of  vaginitis  found  by  a  physician; 
Cambridge,  9  cases  of  masturbation  found  by  nurses  in  care- 
ful follow-up  work;  the  same  number  of  cases  found  in 
Providence  of  this  harmful  habit;  and  91  cases  of  syphilis 
found  by  the  doctors  in  Boston. 

These  findings  speak  well  for  the  purity  of  our  children 
and  the  homes,  even  though  we  may  be  sure,  as  is  true,  that 
many  cases  were  not  reported  for  personal  reasons  and  be- 
cause this  has  not  yet  been  recognized  as  a  part  of  the  duties 
of  the  health  officers.  When  we  have  careful  inspection  and 
examinations  and  thorough  follow-up  work  we  shall  discover 
much  needed  evidence  for  emphasizing  in  some  manner  sex 
education  of  the  young. 

The  syphilis  cases  were  1.5  per  cent  of  the  children  in- 
spected in  Boston.  Only  this  one  ailment  is  mentioned.  In 
the  other  cities,  the  percentages  are  less  than  one  per  cent. 

Counting  all  cases  actually  present  among  the  children 
and  including  the  habit  mentioned,  certainly  not  less  than  I 
per  cent  are  affected. 

Cornell  (page  554)  emphasizes  knowledge:  "A  thor- 
ough knowledge  of  syphilis  and  gonorrhea  .  .  .  should  be 
gained  by  teacher  and  high  school  student.  Then  there  will 
be  some  hope  of  preventing  these  diseases.  The  salvation 


200     SCHOOL  HEALTH  ADMINISTRATION 

of  these  weakly,  infected  children  depends  largely  upon  the 
recognition  of  the  syphilitic  cases  by  the  school  inspector."5 
No  prudishness  or  sentimental  false  modesty  must  stand 
in  the  way  of  rooting  out  such  ailments  from  the  lives  of  the 
children  if  possible.  According  to  the  old  Greeks  the  wise 
person  is  known  by  his  hates  and  what  he  fights.  Any  study 
of  this  ailment,  brought  upon  the  innocent  as  portrayed  in 
Ibsen's  "Ghosts"  and  Brieux'  "Damaged  Goods,"  will 
disclose  a  combatant,  one  of  the  most  hideous  and  deadly  of 
civilized  life. 

17.    MINOR    SKIN    AILMENTS:    HERPES,     SEBORRHEA,    ACNE 
( BLACKHEADS ),  SIMPLE  RASH,   POISON  IVY,  ETC. 

The  serious  skin  ailments  are  all  given  separate  mention. 
Here  we  have  those  frequent  minor,  non-infectious  ones 
which  furnish  the  nurses  with  so  much  work  in  the  form  of 
treatment  and  follow-up.  Still  certain  cities  do  not  mention 
the  ailments  of  this  group  at  all. 

The  frequencies  are  as  follows:  Summit,  .7  per  cent; 
S.  Manchester,  .6  per  cent;  Norwood,  4  per  cent;  Montclair 
(27  cases),  .8  per  cent;  Mt.  Vernon,  .3  per  cent;  Newton 
(49  cases),  .8  per  cent;  Hoboken  (8  cases),  Schenectady 
(68  cases),  .6  per  cent;  Waterbury,  .3  per  cent;  New  Bed- 
ford, .3  per  cent;  Trenton,  .4  per  cent;  Cambridge,  .9  per 
cent;  New  Haven,  3  per  cent;  Rochester  (300  cases),  2  per 
cent;  Providence,  .8  per  cent;  Newark,  1.7  per  cent;  Boston 
(2,000  cases),  3  per  cent. 

The  average  is  1.2  per  cent,  and  the  deviation  is  large 
as  in  all  cases  where  certain  cities  have  left  out  all  mention 
of  the  ailment. 

What  the  true  percentage  of  new  cases  is  we  hesitate  to 
judge;  but  leave  the  very  tentative  estimate  of  1.5  per  cent. 

1 8.    STOMATITIS,    MOUTH    ULCERS 

Boston  is  the  only  city  which  emphasizes  this  ailment, 


*Cornell    reports    also    that    in  institutions    for    the    feeble    minded 
twenty  per   cent  of  the  inmates   are  victims  of  syphilis. 


NON-COMMUNICABLE  AILMENTS        201 

although  there  are  four  other  mentions  of  it  with  only  7 
cases. 

Counting  the  number  of  cases  which  the  nurses  saw, 
1 20,  we  have  a  very  small  percentage.  The  nurses  of  Bos- 
ton probably  covered  the  entire  elementary  school  population 
of  nearly  96,000  which  would  give  only  a  .1  percentage. 

We  leave  the  probable  true  number  of  cases  at  this 
figure,  .1  per  cent. 

This  ailment  might  be  recorded  with  minor  skin  ail- 
ments, or  with  malnutrition,  but  it  will  probably  be  best  to 
give  it  separate  mention.  McCombs,  in  his  "Diseases  of 
Children  for  Nurses,"  page  99,  says:  "This  disease  is  very 
common  among  the  poorer  class  of  patients.  It  is  due  to 
uncleanliness  and  to  a  spongy  condition  of  the  mouth  seen 
in  ill-nourished  children.  There  are  several  varieties  named 
according  to  the  appearance  of  the  lesions  in  the  mouth." 

In  most  cities  the  doctors  and  nurses  evidently  miss  this 
ailment. 

19.  WOUNDS,  SORES,   SPRAINS,  CHILBLAINS,   POISON  IVY, 
"FIRST  AID,"  DRESSINGS 

Here  we  have  a  very  common  group  of  ailments  where 
the  nurses  can  be  of  great  assistance.  Children  are  always 
getting  cut,  bruised,  hurt,  and  the  like.  Nose-bleed  might 
also  go  in  this  group.  The  nurse  shows  the  child  how  to 
apply  principles  of  cleanliness  and  simple  medicine  and  so 
not  only  saves  pain  and  possible  infections  or  worse,  but 
educates  the  children  in  a  very  practical  manner. 

It  can  be  seen  that  some  doctors  and  nurses  consider  these 
ailments  within  their  province  and  some  do  not.  Some  also 
may  consider  them  too  trifling  to  report.  However,  if 
they  take  up  time,  and  are  worth  doing,  they  are  worth  re- 
porting; and  this  is  the  more  general  custom. 

Eleven  cities  either  give  no  mention  or  report  exceedingly 
few  cases.  Eight  are  board  of  education  cities  and  three 
are  board  of  health. 

The  larger  percentages  are  as  follows:  Norwood,  22 
per  cent;  Winchester,  77  per  cent;  Montclair  (187  cases), 


202     SCHOOL  HEALTH  ADMINISTRATION 

5  per  cent;  Newton,  2  per  cent;  Hoboken  (8  cases)  ;  Yonkers 
(3  cases)  ;  New  Bedford,  .3  per  cent;  New  Haven,  1.5  per 
cent;  Providence,  1.6  per  cent;  Newark,  14  per  cent;  Boston, 
10  per  cent. 

These  variations  are  extreme.  Large  perceentages  mean 
both  a  number  of  treatments  of  the  same  case,  and  real 
solicitude  and  care  of  the  children,  most  probably. 

The  average  for  the  percentages  given  is  15  per  cent. 

This  number,  taking  all  facts  into  consideration,  may 
probably  represent  fairly  accurately  the  actual  number  of 
new  cases  among  the  elementary  school  population  in  any 
one  year  which  need  the  attention  of  the  nurses,  and  which 
may  come  also  to  the  attention  of  physicians. 

2O.  URINARY  AILMENTS,  ENEURESIS,  RENAL  TROUBLE,  FRE- 
QUENT REQUESTS  TO  LEAVE  THE  ROOM,  INCON- 
TINENCE OF  URINE 

This  weakness  of  children  is  quite  common  but  does  not 
receive  very  frequent  mention.  Some  selected  percentages  of 
cities  that  seem  to  have  had  their  attention  drawn  to  this 
ailment  are:  Montclair,  .4  per  cent;  Cambridge,  .2  per 
cent;  Providence,  .06  per  cent;  Boston,  .1  per  cent. 

For  an  estimate  of  little  value,  we  place  the  average  at 
.2  per  cent  as  the  actual  number  of  such  cases. 


CHAPTER   EIGHT 

COMMUNICABLE  AILMENTS,  PARASITIC  AND 
INFECTIOUS 

II.  COMMUNICABLE,  OR  TRANSMISSABLE  AILMENTS 

Here  we  enter  the  second  grand  division  of  ailments 
which  are  of  a  very  serious  character  because  they  can 
rapidly  be  passed  from  child  to  child.  Serious  doubt  is 
thrown  over  the  old  theory,  that  such  diseases  as  Scarlet 
Fever  and  Diphtheria  are  propagated  and  diffused  princi- 
pally at  the  schools,  by  Dr.  Chas.  V.  Chapin,  Superintendent 
of  Health  of  the  city  of  Providence,  Rhode  Island  (Annual 
Report  for  1911  and  former  reports).  His  data,  reaching 
back  to  1885,  also  throw  reasonable  doubt  over  the  theory 
that  disinfection  and  certain  forms  of  exclusion  are  neces- 
sary in  the  case  of  such  ailments.  We  very  much  need  rigid 
tests  of  all  these  old  suppositions  by  scientific  procedure, 
and  the  whole  subject  bristles  with  unsolved  or  untouched 
problems.  The  number  of  deaths  caused  by  the  more  seri- 
ous of  these  ailments  is  given  elsewhere,  both  for  the  coun- 
try, page  — ,  and  for  the  cities,  table  — ,  columns  — .* 

The  living  organisms  causing  these  ailments  are  mostly 
animals,  but  some  are  plants,  ringworm  and  favus  being  due 
to  fungi.  The  animals  vary  in  size  from  the  large  and 
very  common  louse  down  to  the  itch-mite,  almost  too  small 
for  the  naked  eye,  and  thence  rapidly  down  to  the  micro- 
scopic and  almost  undiscoverable  germs,  or  bacilli,  so  well 
described  zoologically  in  such  books  as  Hough  and  Sedg- 
wick,  uThe  Human  Mechanism,"  and  even  Ritchie's 
"Primer  of  Sanitation." 


*See  also  the  1912  N.  E.  A.  Proceedings,  article  by  Professor  Jor- 
dan, of  the  University  of  Chicago. 

203 


204    SCHOOL  HEALTH  ADMINISTRATION 

A.  Parasitic  and  Minor  Infectious  Ailments 

For  a  long  time  the  writer  kept  only  the  parasitic  ail- 
ments in  this  class.  They  are  ailments  which  it  is  the 
special  duty  of  the  nurses  to  drive  out  of  existence  as  nearly 
as  possible.  But  conjunctivitis,  impetigo,  grippe,  and  ton- 
silitis  all  seemed  later  to  belong  to  this  class  more  than  to 
the  serious  infectious  diseases  which  may  be  death-dealing. 
The  advantages  of  such  a  classification  need  not  here  detain 
us.  Its  value  will  come  out  by  use,  and  will  stand  or  fall 
on  how  well  it  serves  its  purpose. 

I.    CONJUNCTIVITIS,    PINK    EYE.     COLUMNS     137-8 

The  various  forms  of  conjunctivitis  are  not  differen- 
tiated here.  They  are  very  infrequently  separated  in  the 
reports.  The  pupil's  record  card  may  well  contain  the 
specific  name,  but  for  general  reporting  the  single  term  is 
probably  best  until  the  need  arises  for  more  detailed  report- 
ing. The  most  common  form  is,  perhaps,  the  "pink  eye" 
which  frequently  plays  such  havoc  with  attendance  in  the 
primary  grades. 

In  the  case  of  conjunctivitis,  as  with  most  infectious  ail- 
ments, some  cities  report  only  the  excluded  cases.  For  the 
serious  ailments  this  will  be  equivalent  to  the  entire  number 
of  suspected  or  actual  cases,  but  this  is  not  true  for  several 
of  the  minor  ailments.  The  parasitic  ailment  cases  may  all 
remain  in  school  with  proper  precautions. 

Some  of  the  frequencies  for  conjunctivitis  are  as  fol- 
lows:— The  first  three  cities,  only  three  cases  reported; 
Winchester  (15  cases  excluded),  i  per  cent;  West  Orange, 
3  per  cent;  Montclair,  3  per  cent;  only  9  cases  in  the  next 
four  cities;  Hoboken,  .8  per  cent;  Schenectady,  2.3  per  cent; 
Waterbury,  .8  per  cent;  Yonkers,  .4  per  cent;  N.  Bedford, 
.4  per  cent;  Trenton,  i  per  cent;  Cambridge,  .5  per  cent; 
Syracuse,  .9  per  cent;  Providence,  .4  per  cent;  Newark, 
1.6  per  cent;  Boston  (1,526  cases),  2  per  cent. 

The  average  is  1.3  per  cent.  Seemingly,  the  more  care- 
ful and  thorough  the  inspection  or  examination,  the  closer 
the  percentage  comes  to  two  per  cent,  or  more. 


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208     SCHOOL  HEALTH  ADMINISTRATION 

We  leave  the  estimate  that  nearly  three  per  cent  of  the 
elementary  school  children  are  probably  affected  with  con- 
junctivitis in  any  one  school  year. 

2.   FAVUS,  YELLOW  SCALP  SORES,   FUNGUS   PARASITE 

This  ailment,  while  relatively  infrequent  fortunately,  is 
yet  very  stubborn  in  resisting  cure.  Fortunately,  also,  it  is 
not  very  infectious. 

One  of  the  best  illustrations  of  the  tremendous  resistance 
it  offers  to  curative  agents  appears  in  the  Dunfermline,  Scot- 
land, report  for  1911-12,  previously  mentioned.  Three 
cases  attended  the  school  clinic  for  treatment  during  the  year 
283  times,  an  average  of  94  visits  each,  and  even  after  these 
we  have  no  statement  of  cure. 

Some  of  the  other  averages  for  visits  given  in  this  re- 
port for  the  ailments  in  this  group  may  perhaps  as  well  be 
stated  here : 

No.  of  Aver.  No. 

Cases.  Attendances,  of  Visits. 

Conjunctivitis     46  455  10 

Phyctenular  conjunctivitis 15  320  21 

Ringworm   of   scalp 26  337  13 

Ringworm  of  body 7  53  7 

Impetigo    223  1,127  5 

Scabies,  itch   22  150  7 

Favus    3  283  94 

The  average  number  of  visits  of  2,058  cases  treated  at 
this  school  clinic  (14,493  visits)  was  seven  visits. 

The  English  Board  of  Education  reports  also  point  to 
favus  as  being  the  most  difficult  in  point  of  time  of  all  these 
ailments  to  cure.  It  can  be  seen  that  a  nurse  could  treat 
such  an  ailment  almost  every  day  of  the  school  year,  per- 
haps, before  effecting  a  cure. 

Favus  is  rather  uncommon  and  the  frequencies  are  low: 
Yonkers,  .3  per  cent;  Newark  (28  cases),  .1  per  cent.  The 
other  cities  stand  below  these  figures. 

Our  estimate  for  all  cities  is  .1  per  cent,  or  one  case  in  a 
thousand.  This  is  practically  the  percentage,  also,  for  New 
York  City. 


COMMUNICABLE  AILMENTS  209 

3.    IMPETIGO,   OR   IMPETIGO    CONTAGIOSO 

This  contagious  skin  disease,  frequently  transmitted 
through  towels,  perhaps,  is  characterized  by  several  large 
flat  scabs,  or  pustules  which  break  early  and  form  crusts.  It 
most  frequently  appears  on  the  face. 

Some  of  the  frequencies  are:  Summit,  .5  per  cent;  Nor- 
wood, 1.4  per  cent;  Winchester,  4  per  cent;  Montclair,  2 
per  cent;  Hoboken,  .4  per  cent;  Waterbury,  1.8  per  cent; 
Yonkers,  .5  per  cent;  New  Bedford,  1.6  per  cent;  Cam- 
bridge, .2  per  cent;  Lowell,  .8  per  cent;  Jersey  City,  .3  per 
cent  excluded;  Newark,  i  per  cent  (nurses  made  7,389 
treatments,  and  perhaps  found  many  more  new  cases)  ;  Bos- 
ton, 2  per  cent. 

The  average  is  1.3  per  cent.  Impetigo  is  probably  more 
common  than  this  figure  represents. 

The  Montclair  estimate  of  2  per  cent  seems  nearer 
what  may  be  found  on  careful  examination  of  all  elementary 
children  in  each  city. 

4.    INFLUENZA,    GRIPPE 

Boston  is  the  only  city  which  gave  very  much  attention 
to  this  ailment.  Only  six  other  cities  mention  it,  with  very 
few  cases,  some  of  which  were  excluded  from  school. 

The  Boston  percentage  is  .1  or  .2.  We  cannot  tell,  for 
sure.  The  inspection  really  covered  the  entire  city,  and 
even  the  parochial  school  ailments  are  included.  The  num- 
ber of  children  was  about  90,000  to  95,000.  This  would 
reduce  Boston's  percentages  based  upon  the  61,000  inspec- 
tions. For  the  inspected  cases  were  picked  out  by  the  teach- 
ers and  nurses  as  suspected  cases  from  the  entire  number. 

We  leave  the  probable  number  of  cases  actually  present 
in  the  elementary  school  population  for  any  one  year  in 
the  average  school  system  at  a  maximum  of  .1.  This  is 
only  a  guess  and  the  figure  will  very  probably  be  changed 
with  further  investigation. 

5.    PEDICULOSIS,   LICE — BODY  AND   HEAD.    COLUMNS    145-6 
This  is  the  most  frequent  ailment  found  in  the  schools, 
with  the  exception  of  teeth.    It  can  be  said  without  qualifka- 


210    SCHOOL  HEALTH  ADMINISTRATION 

tion  that  no  other  school  ailment  takes  up  so  much  time 
and  money  spent  for  doctors  and,  especially,  nurses.  It  is 
a  national  disgrace,  of  course,  that  this  is  true;  but  it  is  only 
by  facing  such  facts  that  we  shall  eradicate  them.  Some 
cities  started  medical  inspection  for  the  special  purpose  of 
ridding  the  schools  of  this  pest.  The  President  of  the  Board 
of  Education  at  South  Manchester  told  the  writer  that  the. 
plan  was  started  in  the  hope  that  one  year  or  two  would 
eliminate  the  evil  entirely.  After  eight  years,  the  ailment 
is  comparatively  common,  although  reduced  in  frequency, 
and  limited  to  a  few  families.  The  real  remedy  for  such 
ailments  lies  in  the  homes. 

A  girl  with  long  hair  suffering  from  this  ailment  may 
be  treated  and  found  free  from  pediculi  or  their  eggs  (nits) 
and  called  cured,  and  yet  in  a  week  or  two  be  found  in- 
fected again.  This  makes  our  number  of  cases  much  larger 
than  the  number  of  children  affected.  Just  how  much  the 
percentages  should  be  reduced  for  these  considerations,  we 
cannot  say.  It  is  probable  that  a  child  should  be  counted 
but  once,  no  matter  how  many  recurrences  there  are  during 
the  school  year.  Each  of  the  latter  can  be  counted  by  the 
nurse  as  inspected  or  treated,  or  both. 

The  percentages  for  the  figures  as  recorded  are  as  fol- 
lows: Summit,  n  per  cent;  S.  Manchester,  4  per  cent; 
Norwood,  24  per  cent;  Winchester,  9  per  cent;  West 
Orange,  4  per  cent;  Montclair,  10  per  cent;  Meriden,  7 
per  cent;  Newton,  5  per  cent;  Brockton,  15  per  cent;  Ho- 
boken,  4  per  cent;  Schenectady,  17  per  cent;  Waterbury, 
37  per  cent;  Yonkers,  4  per  cent;  N.  Bedford,  10  per  cent; 
Trenton,  i  per  cent;  Cambridge,  2  per  cent;  Lowell,  4  per 
cent;  New  Haven,  14  per  cent;  Syracuse,  6  per  cent;  Roch- 
ester, 2  per  cent;  Providence,  13  per  cent;  Jersey  City,  .7 
per  cent;  Newark,  n  per  cent;  Boston,  12  per  cent. 

The  average  is  9  per  cent. 

The  actual  number  of  different  elementary  school  chil- 
dren afflicted  with  this  ailment  in  any  one  school  year  is 
certainly  not  over  5  per  cent,  or  one  in  twenty,  about  two 
pupils  to  every  school  room,  some  time  in  the  year  on  the 


COMMUNICABLE  AILMENTS  211 

average.  The  entire  difficulty  illustrates  the  practical  im- 
possibility of  getting  accurate  facts  from  these  reports,  as 
they  were  then  and  are  still  made  up.  The  number  of  cases 
is  astoundingly  large,  at  any  rate,  and  it  is  hard  to  believe 
that  on  the  average  about  five  per  cent  of  the  elementary 
school  children  have  head  lice  at  some  time  in  each  school 
year.  (Body  lice  are  very  infrequent.) 

6.   RINGWORM,   TINEA,    BODY  AND   SCALP 

This  is  another  ailment  due  to  a  fungus  vegetable  para- 
site, and  one  which  takes  time  and  care  to  cure.  Children 
under  strict  supervision  and  regular  treatment  may  be  per- 
mitted to  attend  school.  The  treatment  in  England,  Scot- 
land and  Germany  is  more  efficient  than  in  this  country. 
The  chief  method  of  treatment  there  is  by  the  X-rays.  Diag- 
nosis is  made  with  the  help  of  microscopic  examinations. 
The  best  reports  of  ringworm  among  school  children  are 
found  in  the  1910  and  1911  reports  of  the  Chief  Medical 
Officer  of  the  Board  of  Education  of  England. 

We  may  be  sure  that  the  ailment  exists  in  every  city  of 
any  size,  although  we  have  cities  in  this  list  of  twenty-five 
that  have  made  no  mention  of  it.  In  Summit  the  cases  are 
not  separated  from  other  skin  ailments.  Scalp  cases  are 
more  difficult  to  cure,  and  this  makes  desirable  separate 
records  of  the  two  cases.  The  English  report  shows  aver- 
age length  of  exclusions  from  school  for  this  ailment  as 
high  as  ten  months.  At  Croyden,  England,  "the  more  se- 
vere cases  have  been  dealt  with  by  X-ray  treatment  for 
several  years  past,  and  the  average  time  taken  to  complete 
the  cure  of  425  children  has  been  73  days,  i.  e.,  approxi- 
mately, 10  weeks."  Bradford,  England,  seems  to  give  the 
best  general  handling  and  treatment  of  this  ailment.  Eigh- 
teen cities  or  urban  districts  have  X-ray  apparatus  at  their 
school  clinics  or  have  portable  apparatus.  In  several  places 
ringworm  classes  have  been  established.  This  gives  at  once 
isolation  from  other  children,  and  a  continuance  of  school- 
ing. 

In  none  of  the  American  cities  studied  in  this  investiga- 


212     SCHOOL  HEALTH  ADMINISTRATION 

tion  has  there  been  any  special  study  and  investigation  of 
this  ailment,  of  which  the  writer  has  learned. 

Some  of  the  frequencies  are :  In  the  first  five  cities, 
only  10  cases  given  separate  mention,  six  of  whom  were 
excluded;  Montclair  (33  cases),  i  per  cent;  Meriden,  .2 
per  cent;  Hoboken  (36  cases),  .4  per  cent;  Yonkers  (14 
cases),  .1  per  cent;  New  Bedford  (174  cases),  1.5  per 
cent;  Trenton,  only  5  cases  reported  by  one  nurse,  probably 
15  in  all,  .1  per  cent;  Cambridge,  .1  per  cent;  Providence, 
.2  per  cent;  Jersey  City  (38  cases  excluded),  .1  per  cent; 
Newark,  3,209  cases  excluded  and  treated  by  nurses,  13 
per  cent  (doctors'  cases,  162,  or  .7  per  cent)  ;  Boston,  504 
cases,  .6  per  cent. 

In  Newark,  the  supposition  is  that  13  per  cent  does  not 
represent  the  number  of  different  children  affected,  but  the 
number  of  exclusions,  many  children  probably  having  been 
excluded  more  than  once. 

The  average  percentage  seems  to  be  near  .4  per  cent. 
Any  estimate  of  the  actual  number  of  new  cases  found  or 
to  be  found  in  any  one  school  year,  not  counting  any  child 
twice,  is  precarious.  Probably  .4  per  cent,  or  4  cases  in  a 
thousand  would  be  near  the  truth. 

7.    SCABIES,   ITCH 

The  folk  term,  "slow  as  the  seven  years'  itch,"  indicates 
what  has  been  the  character  of  this  ailment  in  the  past. 
Now,  with  sulphur  ointment  and  baths  and  boiling  or  bak- 
ing of  clothing,  the  ailment  can  be  killed  in  a  few  days.  If 
care  is  not  taken  to  kill  off  every  itch-mite  burrowing  along 
or  resting  in  the  skin,  the  ailment  may,  however,  last  in- 
definitely. In  the  minds  of  many  physicians  the  ailment  is 
associated  with  promiscuous  sex  relations  but,  as  in  the  case 
with  venereal  diseases,  the  innocent  are  not  immune  and  are 
frequent  victims.  As  with  pediculosis,  constant  scratching 
and  marks  of  scratches  on  the  body  or  in  the  web  between 
the  fingers,  are  common  indices.  Many  cities  now  keep 
sulphur  ointment  for  cure  and  furnish  prescriptions,  as  in 
the  cases  of  vermin  and  other  parasitic  ailments. 


COMMUNICABLE  AILMENTS  213 

The  ailment  is  even  more  common  than  ringworm,  and 
very  much  more  distressing  to  the  children  afflicted.  Some 
of  the  frequencies  are  as  follows :  Only  8  cases  given 
separate  mention  in  the  first  three  cities;  Winchester  (12 
cases  excluded),  .8  per  cent;  Montclair,  .4  per  cent;  Mt. 
Vernon,  .2  per  cent;  Hoboken,  .2  per  cent;  Schenectady,  .2 
per  cent;  Waterbury,  .1  per  cent;  Yonkers,  .12  per  cent; 
New  Bedford,  i.i  per  cent;  Trenton,  .1  per  cent;  Cam- 
bridge, .2  per  cent;  Syracuse,  .3  per  cent;  Rochester,  .2  per 
cent;  Providence  (158  cases  excluded),  .5  per  cent;  Jersey 
City,  .04  per  cent  excluded;  Newark,  .8  per  cent  excluded; 
Boston  (648  cases),  .8  per  cent. 

The  average  number  of  cases  or  exclusions  is  almost  .5 
per  cent.  The  average  number  of  cases  among  the  ele- 
mentary school  population  in  any  one  year,  counting  no  case 
twice,  is  probably  not  far  from  four  in  a  thousand,  and  per- 
haps five,  say  five.  The  variation  is  perhaps  from  about 
2  to  ten  in  a  thousand,  although,  as  we  have  found  it,  the 
variations  among  physicians  and  nurses  exceeds,  and  so 
covers  up,  the  probable  variability  of  cities. 

8.  TONSILITIS,   QUINSY 

This  is  generally  a  rather  mild  ailment,  but  may  easily 
be  confused  with  the  beginnings  of  several  of  the  infectious 
diseases;  so  it  is  treated  almost  as  rigorously  as  if  it  were 
a  suspected  case  of  diphtheria.  The  Chicago  Board  of 
Health  rule  is:  "Cases  of  tonsilitis  must  be  excluded  on 
the  clinical  evidence  alone,  and  throat  cultures  made  for 
further  diagnosis."  It  is  possible  for  school  purposes  that 
the  ailment  may  be  placed  with  "sore  throat"  cases,  since 
the  treatment  is  practically  the  same.  Where  doctors  and 
nurses  are  sure  that  the  case  is  tonsilitis  and  not  some  other 
form  of  sore  throat,  probably  infectious,  we  have  a  situation 
where  it  is  better  to  have  separate  mention  of  the  ailment. 

The  ailment  is  an  inflammation  of  the  tonsils  which  may 
become  an  abscess.  The  latter,  by  breaking  while  the  pa- 
tient is  sleeping,  may,  according  to  Dr.  Ditman  (Home 
Hygiene  and  the  Prevention  of  Disease),  cause  suffocation. 


2i4    SCHOOL  HEALTH  ADMINISTRATION 

The  abscess  should  be  opened  by  a  physician.  The  preven- 
tion is  along  the  line  of  preventing  colds,  keeping  up  the 
resistance,  and  removing  enlarged  tonsils. 

A  few  random  frequencies  among  the  elementary  school 
populations  are:  Montclair,  1.3  per  cent;  Hoboken,  .7 
per  cent;  Yonkers,  .15  per  cent;  New  Bedford,  .6  per  cent; 
Trenton,  .2  per  cent;  Cambridge,  .4  per  cent;  Rochester, 
.15  per  cent;  Jersey  City,  .06  per  cent;  Newark,  1.4  per 
cent;  Boston  (1,200  cases),  1.3  per  cent. 

The  average  is  .76  per  cent. 

The  actual  number  of  new  cases  among  the  elementary 
school  population  during  any  one  school  year  is  probably 
not  less  than  one  per  cent.  This  is  our  estimate.  Most 
cities  simply  have  not  found  or  have  not  recorded  all  cases. 
Less  than  a  half  per  cent  Would  certainly  indicate  this. 

We  have  now  completed  our  survey  of  minor  infectious 
and  parasitic  ailments.  Mulloscum  contagiosum  is  a  very 
uncommon  ailment  belonging  to  this  group,  but  is  not  given 
separate  mention,  only  10  cases  having  been  found  in  one 
city,  Newark.  Hookworm  is  another  serious  ailments  of 
this  class  that  should  be  included  wherever  the  ailment  is 
found,  and  it  seems  rather  widespread,  from  reports  of 
Rockefeller  Institute. 

B.  Infectious  Diseases 

Here  we  come  to  those  diseases  which  started  medical 
inspection  by  health  departments  in  cities,  in  the  effort  to 
control  the  causes  of  death  among  the  young.  Beginning 
here,  the  study  of  causes  and  prevention  has  led  to  the  dis- 
covery of  a  host  of  previously  unrecognized  ailments  which 
are  only  indirectly,  if  at  all,  death-dealing.  Present  studies 
seem  to  show  that  the  school  is  a  very  slight  factor  in  the 
spread  of  infectious  ailments,  contrary  to  the  long  accepted 
opinion;  and,  moreover,  it  is  surprising  how  small  a  per- 
centage of  the  actual  cases  are  found  in  the  schools  before 
they  are  found  and  isolated  by  the  parents  or  family  phy- 
sicians. It  must  be  remembered  in  this  list  that  many  of 
the  cases  reported  or  excluded  are  only  suspected  cases,  and 


COMMUNICABLE  AILMENTS  215 

that  a  further  large  number  of  children  have  been  excluded 
because  they  lived  in  the  same  family  or  same  house  as  those 
ill.  An  interesting  and  needed  study  is  the  comparison  of 
the  number  of  cases  reported  by  boards  of  health  and  the 
numbers  found  which  actually  prove  to  be  cases  by  the 
school  medical  service.  Another  dangerous  factor  is  the 
disease  carrier,  a  child  healthy  but  carrying  and  distributing 
deadly  bacilli. 

We  should  expect  that  those  inspectors  and  nurses  under 
boards  of  health  would  make  a  better  showing  in  the  field 
we  have  now  entered  than  the  board  of  education  medical 
workers,  for  some  of  them  have  done  little  else  than  look 
out  for  and  report  suspected  infectious  cases.  Let  us  see. 

In  the  table,  excluded  cases  are  marked  X,  merely  sus- 
pected cases  where  so  reported  are  marked  with  a  ?. 

I.   CHICKEN   POX,   VARICELLA 

Summit  school  health  officers  found  no  cases  of  in- 
fectious or  suspected  infectious  diseases  in  the  schools  dur- 
ing the  year,  so  far  as  I  could  learn  from  the  superintend- 
ent and  physician.  Many  cases  actually  occurred,  however, 
and  the  schools  learned  of  them  through  reports  of  the 
Board  of  Health.  In  the  writer's  opinion,  infectious  dis- 
eases are  a  most  important  part  of  school  health  records 
whether  cases  are  found  in  the  schools  or  not.  The  number 
of  cases  of  these  ailments  and  the  number  of  deaths  of  chil- 
dren of  school  age  in  each  city  are  given  in  the  tables. 

Eight  children  were  recorded  as  having  had  treatment 
in  Norwood,  .7  per  cent  of  the  elementary  school  children; 
Winchester,  1.3  per  cent;  West  Orange,  .7  per  cent  ex- 
cluded; Montclair,  i  per  cent;  Meriden,  .2  per  cent;  Mt. 
Vernon,  only  one  case  excluded;  Newton,  .4  per  cent  prob- 
ably excluded;  Hoboken,  .3  per  cent;  Trenton,  with  a  large 
medical  force,  comparatively,  and  over  10,000  examinations 
and  8,000  special  inspections,  and  3,400  inspections  by 
nurses,  found  only  one  case  of  chicken  pox  in  the  schools; 
Cambridge,  1.5  per  cent;  no  cases  reported  by  either  Lowell 
or  New  Haven,  the  latter  under  the  Board  of  Health; 


216    SCHOOL  HEALTH  ADMINISTRATION 

Syracuse,  .2  per  cent;  Jersey  City,  .06  per  cent;  Newark,  .9 
per  cent  (better  reduced  to  .5  per  cent  by  using  not  the 
number  examined  but  the  entire  elementary  school  enroll- 
ment, perhaps,  as  explained  elsewhere)  ;  Boston  (based  on 
elementary  school  enrollment,  not  on  number  of  inspections 
of  special  cases,  counting  500  cases  found  by  both  doctors 
and  nurses),  .5  per  cent.  Several  cities  have  been  left  out, 
as  usual,  because  the  cases  found  were  so  few.  They  are 
not  representative. 

The  average  frequency  of  suspected,  or  actual,  cases 
found  in  the  schools  according  to  these  summaries  is  .6  per 
cent. 

This,  perhaps,  is  near  the  actual  number  of  cases.  We 
cannot  tell.  Many  of  the  cases  found  are  children  who 
have  returned,  in  the  opinion  of  doctor  or  nurses,  too  early. 

2.  DIPHTHERIA 

This  dread  disease  is  well  known,  but  science  is  gaining 
control  over  it.  The  most  remarkable  decreases  in  fatalities 
from  any  disease  are  shown  for  this  ailment  and  typhoid. 
The  1911  Board  of  Health  report  for  Boston  (pages 
182-3)  shows  that  in  1878  and  many  years  later  the  ratio 
of  deaths  to  number  of  cases  was  nearly  half,  and  not  as 
low  as  one  out  of  three  dying  until  1889.  But  since  1907 
the  percentages  have  ranged  around  6  per  cent,  or  about 
one  out  of  fifteen  or  sixteen  cases  ill. 

Still  there  were  2,081  deaths  from  this  disease  in  1910, 
so  it  is  yet  a  very  real  terror. 

Fewer  cases  or  suspected  cases  of  this  ailment  were 
found  than  in  the  case  of  chicken  pox,  17  cities  giving 
practically  no  mention  of  it.  The  most  interesting  struggle 
with  infectious  diseases  in  any  of  the  cities  during  the  years 
studied,  was  probably  that  in  South  Manchester.  There 
were  three  epidemics;  one  of  diphtheria,  one  of  scarlet 
fever,  and  another  of  measles.  The  school  physician  was 
paid  an  extra  hundred  dollars  to  inspect  almost  all  the 
children  in  the  school  system  once  a  week  for  six  weeks. 
(See  1911  report.)  The  health  department  and  the  school 


COMMUNICABLE  AILMENTS  217 

officials  did  everything  possible  but  the  epidemics  continued 
almost  as  if  nothing  were  being  done.  Here  we  have  a 
very  severe  test  of  school  medical  inspection. 

One  thousand  six  hundred  and  ninety-three  days  were 
lost  from  school  by  65  pupils  ill  with  diphtheria,  and  1,666 
by  73  others  quarantined  because  of  exposure,  a  total  of 
3,359  days  (number  excluded,  138).  For  scarlet  fever 
other  pupils  exposed,  2,728  days,  a  total  of  4,731  days, 
there  were  lost  by  75  children  ill,  2,003  days,  and  for  71 
Diphtheria  occurred  in  67  families  and  scarlet  fever  in  65. 

In  the  inspections,  585  cultures  were  taken,  of  which 
143  were  reported  positive.  Some  carriers  were  found. 
These  tend  to  show  that  the  number  of  cases  might  have 
been  greater  had  there  not  been  the  extraordinary  inspec- 
tion. On  the  whole,  however,  it  shows  the  probable  limita- 
tions of  school  inspection.  The  schools  were  not  closed 
during  the  epidemics,  as  would  be  the  cases  in  many  cities 
so  stricken.  Three  children  died  of  diphtheria.  At  the  end 
of  the  year  it  was  found  that  the  promoted  pupils  had  lost 
on  an  average  32  of  the  186  school  days,  while  the  non- 
promoted  pupils  lost  52  days,  a  difference  of  six  and  ten 
weeks.  How  much  was  due  to  the  absence,  or  from  the 
absence  for  any  one  cause  was  not  worked  out. 

The  President  of  the  Board  of  Education,  also  a  member 
of  the  State  Board  of  Education  of  Connecticut,  estimated 
the  cost  to  the  schools  of  the  diphtheria  and  scarlet  fever 
cases  at  $2,500;  these  and  lesser  infectious  diseases  like 
measles,  at  $5,000,  all  as  "ineffective  expenditures. "  And 
"we  cannot  estimate  the  cost  to  individuals,  but  assuming 
that  the  serious  diseases  cost  the  parents  even  so  low  an 
average  as  $25.00  each,  and  the  milder  ones  $10.00,  the 
direct  burden  would  be  in  excess  of  $5,000.  If  to  this  were 
added  the  expenses  of  the  health  officer,  and  wages  lost  by 
quarantines,  we  are  certainly  within  the  truth  in  affirming 
that  the  sum  of  the  expenses  of  the  town  and  individuals 
incidental  to  contagious  diseases  was  not  less  than  $12,000, 
and  may  easily  have  been  $15,000." 


218     SCHOOL  HEALTH  ADMINISTRATION 

The  Superintendent's  reasoning  on  the  cost  of  these  ail- 
ments is  shown  in  the  following  paragraph: 

"The  total  time  lost  by  children  who  were  excluded  for 
the  two  diseases  was  8,090  days.  This  was  equivalent  to  44 
school  years  for  one  pupil  or  44  children  lost  one  year's 
schooling.  Last  year  it  cost  $35.28  to  promote  one  pupil 
one  grade.  The  44  years  of  time  lost  had  a  money  equiva- 
lent of  $1,552.  If  to  this  sum  should  be  added  the  time 
lost  by  the  children  where  parents  kept  them  from  school 
through  fear  of  contagion,  and  those  who  were  absent  sev- 
eral days  awaiting  the  report  of  cultures,  it  is  probable  that 
the  sum  would  be  about  $2,500  in  time  lost  by  children 
absent  from  school.  To  this  must  be  added  the  time  con- 
sumed by  teachers  in  attempts  to  bring  the  absent  pupils 
back  to  grade  which  always  contains  an  element  of  loss  to 
the  pupil  who  attends  regularly  and  who  loses  some  portion 
of  the  teacher's  time  expended  upon  the  irregular  pupil. 
.  .  .  There  were  three  deaths  from  diphtheria,  a  loss  to 
parents  which  cannot  be  computed  in  money  and  in  which 
they  have  the  sympathy  of  the  whole  community." 

We  give  a  page  or  so  to  the  Manchester  experiment  to 
show  the  loss  of  this  and  other  such  ailments  to  a  com- 
munity; to  indicate  the  limitations  in  even  a  small  city  on 
health  control;  and  to  point  out  a  statistical  fallacy  which 
has  become  very  frequent  in  school  reports  since  Ayres' 
publication  of  such  fiscal  studies,  also  fallacious. 

On  the  second  point,  Mr.  Cheney  urges  a  contagious 
hospital  for  the  town,  and  to  the  writer  suggested  the  very 
great  need  of  state-pay  for  laborers  who  were  quarantined 
in  order  that  effective  quarantine  may  be  obtained.  "The 
infectious  ailments  spread  in  the  mills,  principally,  and  on 
the  streets,  and  not  so  much  in  the  schools,"  he  said. 

This  points  out  one  of  the  most  important  problems  of 
medical  inspection — that  of  preventing  the  spread  of  infec- 
tious diseases  outside  of  the  schools,  on  the  streets  and  in 
the  backyards  where  children  play,  and  also  in  the  mills 
and  stores  where  children,  youths  and  adults  work.  It  is  a 
nice  problem  for  real  investigation. 


COMMUNICABLE  AILMENTS  219 

The  fiscal  fallacy  is  in  computing  the  cost  of  retardation 
and  school  absence  without  any  regard  to  the  economic  laws 
of  diminishing  expense. 

Illness,  exclusion,  and  quarantine  absence  can  be  rela- 
tively accurately  computed;  and,  with  great  care,  some 
notion  of  the  effect  these  absences  have  upon  retardation 
can  be  ascertained;  the  costs  to  parents  and  other  such  items 
can  be  worked  out;  but  the  loss  to  a  school  system  in  money 
from  either  absence  or  retardation  cannot  easily  be  dis- 
covered, and  has  not  yet  been  done.  School  rooms  are  not 
very  often  used  to  their  full  capacity  all  the  time.  The 
pupils  of  any  building  who  fail  in  any  one  year,  can  usually 
be  accommodated  in  the  same  building.  Promotions  are 
made  somewhat  upon  the  basis  of  the  number  of  vacant 
seats  to  be  in  the  room  above.  Pupils  in  the  upper  grades 
of  crowded  districts  are  frequently  sent  to  other  schools 
where  there  are  uncrowded  class  rooms.  A  number  of  chil- 
dren fail  at  each  annual  promotion,  and  yet  no  new  teachers 
are  employed  for  the  building,  no  extra  heat  or  janitor 
service  is  used,  very  little  extra  is  spent  for  supplies.  The 
cost  of  retardation  or  of  absence  almost  disappears  in  the 
situation.  How  much  the  school  system  is  increased  by  the 
damning  up  process  of  retardation,  i.  e.,  how  many  more 
teachers  and  rooms  are  necessary,  has  not  yet  been  dis- 
covered. 

All  the  statistical  studies  of  this  kind,  on  the  Ayres'  plan, 
go  on  the  assumption  that  the  situation  is  the  same  as  if  all 
the  children  failing  of  promotion  each  year  were  put  off 
into  separate  buildings  from  the  main  system.  Thus  Cleve- 
land reports  (1911  Report)  an  appalling  loss  of  school 
money  due  to  retardation.  The  method  is  that  of  multiply- 
ing each  year  of  retardation  by  the  per  capita  cost  of  the 
schools.  Such  figures  may  have  some  pragmatic  value  in 
obtaining  public  support,  but  they  are  undoubtedly  very  far 
from  the  truth.  The  law  of  diminishing  expense  would 
show  that  the  "wasted  expenditures"  were  probably  quite 
small.  So  that  we  must  be  very  careful  in  computing  the 


220    SCHOOL  HEALTH  ADMINISTRATION 

money  cost  of  illness  absence.     The  most  important  losses 
here  are  other  than  financial. 

FREQUENCY  OF  DIPHTHERIA 

South  Manchester,  4.2  per  cent;  none  of  the  other  cities 
have  more  than  one  to  four  cases  until  we  come  to  New 
Haven  with  164  cases,  .7  per  cent;  next  three  cities  with  no 
more  than  four  cases;  Jersey  City,  .1  per  cent;  Newark, 
.1  per  cent;  Boston  (nurses  reporting  752  cases),  .8  per 
cent  of  total  elementary  enrollment.  The  total  number  of 
cases  in  the  city  of  Boston  in  1910  was  2,453. 

The  average  of  these  cases  would  be  relatively  insig- 
nificant. The  general  tendency  can  hardly  be  told  from 
these  figures.  The  average  is,  however,  .  i  per  cent.  The 
number  of  cases,  or  suspected  cases,  is  very  small  compared 
with  the  total  number  of  cases  among  school  children. 

In  New  Bedford,  for  example,  in  the  year  1910  no  sus- 
pected cases,  even,  of  diphtheria  were  found  in  the  schools 
by  the  medical  inspectors,  but  there  were  reported  to  the 
other  division  of  the  Board  of  Health  96  cases  with  24 
deaths.  The  inspectors  did  find  5  suspected  cases  of  measles 
or  children  who  had  returned  too  early;  but  there  were  re- 
ported to  the  contagious  disease  division  697  cases  and  three 
deaths.  Likewise  the  school  inspectors  found  7  cases  or  sus- 
pected cases  of  scarlet  fever  in  the  schools,  while  there  were 
reported  to  the  board  of  health  from  the  homes  246  cases 
and  5  deaths.  All  of  these  persons  with  the  ailment  prob- 
ably were  not  school  children  and  ages  are  not  given  by  ail- 
ments, but  a  very  large  proportion  undoubtedly  were.  We 
leave  it  with  an  estimate  of  12  cases  in  a  thousand  to  be 
found  in  a  school.  All  cases  among  school  children  should 
however  be  recorded  on  the  school  card. 

3.  MEASLES 

This  ailment  is  very  much  better  reported.  The  death 
rate,  too,  is  very  much  lower;  1,112  cases  are  reported  by 
doctors  and  214  cases  by  nurses  in  all  the  cities,  a  percentage 
of  the  entire  elementary  school  population,  counting  1,200 


COMMUNICABLE  AILMENTS  221 

cases  of  all  the  cities,  amounting  to  about  .3  per  cent.  The 
variations  are  from  zero  in  seven  cities  to  5.6  per  cent  in 
Meriden.  The  latter  included  suspected  cases  of  German 
measles. 

The  probable  frequency  of  cases  actually  present  in  a 
school  year  in  an  average  city  is  perhaps  around  .4  per  cent. 

Any  study  of  reports  shows  consternation  and  surprise 
on  the  part  of  superintendents  that  medical  inspection  and 
examination  has  done  so  little  in  controlling  this  ailment.  It 
simply  shows  that  in  this  respect  as  in  many  others  the 
school  must  reach  out  into  the  home  and  other  phases  of 
life  in  order  best  to  serve  the  children. 

Another  point  is,  too,  that  very  little  is  yet  known 
regarding  children's  diseases.  Medical  schools  do  not 
emphasize  the  subject  and  most  medical  research  has  been 
in  other  fields. 

4.  MUMPS 

Of  this  ailment  only  671  cases  or  suspected  cases  are 
reported  by  physicians  and  1,388  cases  by  nurses,  the  Boston 
nurses  contributing  nearly  all  of  these,  1,344  cases.  (Bos- 
ton then  had  35  nurses  and  now  46.)  The  ratio  to  the 
entire  elementary  school  population  in  all  cities  is  (counting 
1,400  cases)  .3  per  cent  plus,  a  little  more  than  for  diph- 
theria. 

No  city  stands  out  here,  except  perhaps  the  nurses'  cases 
in  Boston,  1.5  per  cent.  How  many  of  these  were  duplicates 
we  know  not,  since  the  Boston  report  gives  only  bare  sum- 
maries. Some  of  the  other  frequencies  are:  Newark,  .2 
per  cent  plus;  Rochester,  .08  per  cent;  Yonkers,  .8  per  cent; 
Hoboken,  .08  per  cent;  Meriden,  .3  per  cent;  Montclair 
(nurse,  22  cases),  .7  per  cent;  West  Orange,  .3  per  cent. 

The  average  is  about  .4  per  cent,  about  4  cases  among  a 
thousand  pupils  in  a  school  year. 

5.  SCARLET  FEVER 

The  total  number  of  cases  in  all  cities  reported  by  school 
doctors  is  832  and  by  nurses  676,  nearly  all  of  which  were 


222    SCHOOL  HEALTH  ADMINISTRATION 

furnished  by  the  Boston  nurses.  Probably  the  only  places 
where  cases  were  duplicated  by  the  nurses'  reports  are 
Syracuse,  Providence  and  Boston.  Subtracting  a  hundred 
cases  for  this  and  we  have  left  at  least  1,408  cases  among 
an  elementary  school  enrollment  of  more  than  414,000, 
making  a  frequency  of  .3  per  cent  plus.  Some  of  the  fre- 
quencies are:  South  Manchester,  nearly  5  per  cent;  Win- 
chester, i  per  cent;  New  Haven,  2  per  cent;  Jersey  City, 
.2  per  cent;  Newark,  .05  per  cent  on  total  elementary  enroll- 
ment; Boston,  .6  per  cent. 

The  average  for  these  higher  cities  is  over  i  per  cent. 
We  leave  the  frequency  estimate  at  .4  per  cent  as  a  mini- 
mum ratio. 

6.  TRACHOMA,  GRANULATED  EYE-LIDS 
Of  this  terrible  ailment,  so  guarded  against  at  our  ports 
of  entry  for  immigrants,  there  were  reported  by  the  in- 
spectors 281  cases  in  all  cities,  and  104  cases  by  the  nurses. 
Subtracting  75  cases  from  the  combined  sum  we  have  left 
probably  310  cases,  about  .08  per  cent,  not  far  from  one 
case  in  a  thousand. 

Summit  had  .2  per  cent  nearly;  Mt.  Vernon,  over  .1  per 
cent;  Yonkers  (70  cases),  .5  per  cent;  New  Bedford,  .1 
per  cent  plus;  Cambridge,  .1  per  cent;  Jersey  City,  .07  per 
cent;  Newark  ( 100  cases  treated),  nearly  .2  per  cent. 

We  leave  the  estimate  at  .  i  per  cent,  or  one  case  in  a 
thousand.  Cities  reporting  fewer  cases  than  this  conserva- 
tive estimate  very  probably  haven't  found  the  cases.  The 
cleanest  little  cities  have  cases  of  the  ailment.  Yonkers,  as 
with  almost  all  the  ailments,  shows  very  high  percentages, 
abnormally  so  in  some  cases.  The  indications  are  that  per- 
haps no  city  more  needs  an  enlarged  force  of  doctors  and 
nurses.  Those  in  authority  have  said,  however,  that  Yonkers 
is  such  a  nice  town  that  much  medical  service  in  the  schools 
is  not  needed.  The  number  and  character  of  the  ailments 
point  in  the  other  direction. 

7.    PULMONARY    TUBERCULOSIS,     CONSUMPTION,    PHTHISIS 

This    ailment  is   surprisingly   uncommon   among  school 


COMMUNICABLE  AILMENTS  223 

children  when  the  large  number  of  adults  having  it  are 
taken  into  consideration.  A  number  of  the  cities  had,  and 
more  now  have,  open  air  schools  for  anemic  children  and 
those  with  tubercular  symptoms  or  tendencies.  Probably 
the  most  complete  reports  of  such  work  occur  in  the  South 
Manchester,  Cambridge  and  Newark  reports.  The  von 
Pirquet  skin  test  with  tuberculin  is  used  in  several  places 
to  assist  the  doctors  in  diagnosis.  There  was  much  hope 
that  the  Friedman  antitoxin  would  prove  a  radical  remedy 
and  make  possible  the  rapid  cure  of  all  such  cases.  The 
open  air  schools  would  still  have  their  place,  however,  for 
weak,  anemic,  poorly  nourished  children  can  best  be  fed  and 
cared  for  in  such  a  school.  The  great  need  is,  of  course, 
more  fresh  air  and  outdoor  life  for  all  schools.  What  is 
good  for  a  few  afflicted,  is  good,  and  can  be  provided,  for 
all,  so  far  as  air  is  considered.  Open  window  schools  are 
growing  in  numbers.  A  lowering  of  the  temperature  of 
heating  coils  in  the  fan  rooms,  so  that  air  will  not  be  baked 
and  made  over-sultry,  is  also  very  much  to  be  desired,  and 
will  give  more  nearly  outside  conditions.  Moistening  the 
slightly  heated  (not  much  over  60  degree)  air,  is  also  neces- 
sary in  forced  systems  to  complete  more  nearly  the  supply- 
ing of  the  best  outside  conditions. 

Probably  420  cases  of  suspected  cases  of  pulmonary 
tuberculosis  were  found  in  the  25  cities,  a  percentage  of 
.1  per  cent.  Montclair  had  about  44  children  in  her  open 
air  school,  but  the  number  responding  to  the  tuberculin  test 
is  not  given.  It  is  very  difficult  to  tell,  and  it  is  not  perhaps 
important  to  tell  exactly,  how  many  children  in  the  schools 
actually  have  pulmonary  tuberculosis.  It  is  not  very  hard 
for  the  experienced  physician  or  nurse  to  pick  out  those  chil- 
dren who  run  a  very  great  chance  of  getting  it  and  dying 
from  it  before  they  are  thirty  years  of  age.  If  conditions 
can  be  so  modified  that  no  actual  cases  may  be  found,  a  very 
great  deal  in  the  essential  work  of  prevention  may  be  done. 
Here  is  one  of  the  principal  places  where  the  nurse's  work 
for  home  hygiene  counts  in  the  best  way.  School  feeding 
is  very  important;  good  home  feeding  is  better  if  it  can 


224     SCHOOL  HEALTH  ADMINISTRATION 

be  secured.  Home  ventilation,  cleanliness^  a  chance  to 
play  out-of-doors,  comfortable  clothes,  no  over-work  or 
home  study,  decent  treatment,  plain  nourishing  food,  and 
the  remedying  of  physical  defects  and  ailments:  all  these 
come  within  the  province  of  the  modern  school  nurse  in  the 
service  of  the  coming  generation. 

8.  TUBERCULOSIS  OF  BONES,  JOINTS,  AND  OTHER  PARTS  OF 

THE  BODY 

Enlarged  glands,  when  they  are  found  tubercular,  may 
be  placed  in  this  group.  Pott's  disease  is  a  common  name 
for  tuberculosis  of  the  spine,  the  ailment  which  causes  the 
hunch-back.  Fortunately  this  form  of  tuberculosis  is  very 
infrequent,  only  about  50  cases  being  reported  in  all  the 
cities,  about  .01  per  cent.  Cambridge  reports  27  cases, 
nearly  .2  per  cent;  and  Trenton  has  a  showing  of  18  cases, 
or  over  .1  per  cent.  If  all  the  cases  existing  were  actually 
found  the  percentage  would  not  be  far  from  .1  per  cent  in 
all  cities.  We  leave  it  as  about  that  sum. 

9.  WHOOPING  COUGH,   PERTUSSIS 

This  is  quite  a  common  ailment  and  frequently  the  cause 
of  death.  It  is  one  of  the  greater  time-k.i\\ers  of  all  school 
ailments,  the  period  of  exclusion  being  so  long.  There  was 
a  combined  number  of  693  cases  reported  in  all  cities  of 
which  probably  133  were  duplicates,  leaving  560  cases,  a 
frequency  of  over  .1  per  cent  (.13  per  cent).  Nine  cities 
do  not  mention  the  ailment,  five  boards  of  education  and 
four  boards  of  health.  It  would  seem  that  the  latter  would 
give  especial  attention  to  this  infectious  ailment.  Some  of 
the  frequencies  are:  Winchester,  .6  per  cent;  Montclair, 
.7  per  cent;  Meriden,  .5  per  cent;  Hoboken,  .2  per  cent; 
Providence,  .07  per  cent;  Jersey  City,  .07  per  cent;  New- 
ark, .14  per  cent;  Boston,  .3  per  cent. 

The  higher  percentages  average  .3  per  cent. 

The  probable  number  of  children  in  the  schools  during 
the  school  years  is  perhaps  above  even  this  figure.  But  we 


COMMUNICABLE  AILMENTS  225 

leave  the  probable  percentage  at  .2  per  cent  of  the  ele- 
mentary school  children,  or  two  in  a  thousand. 

SUMMARY  OF  ALL  54  AILMENTS 

We  have  now  come  to  the  end  of  a  long,  hard  journey 
through  the  ills  of  childhood.  We  have  tried  to  look  facts 
in  the  face  and  see  what  these  ailments  are,  how  frequent 
they  are,  how  various  cities  do  their  duty  by  the  ailing  chil- 
dren, and  we  have  also  endeavored  to  develop  tentative 
standard  percentages  which  may  be  the  start  toward  coeffi- 
cients which  will  prophesy  as  accurately  as  insurance  tables 
about  how  many  of  these  various  ailments  we  may  expect 
in  a  school  population,  and  how  far  below  the  normal  vari- 
ous cities  pass., 

The  various  percentages  are  collected  on  a  later  page. 
The  deaths  from  these  ailments  will  also  be  given,  as  well 
as  a  summary  of  the  exclusions.  We  do  not  enter  into  the 
laborious  task  of  testing  each  city  by  these  percentage  stand- 
ards to  determine  its  relative  standing.  If  anyone  cares  to 
do  this  the  figures  are  given  for  it.  Rigorous  comparisons 
are  perhaps  not  now  needed  so  much  as  ideals,  norms,  and 
efficient  methods  of  administration. 


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CHAPTER  NINE 

SPECIAL  PHASES  OF  MEDICAL  INSPECTION  IN 
THESE  CITIES 

IN  PRECEDING  chapters  we  have  attempted  to  describe 
and  evaluate  the  general  administration  of  medical  inspec- 
tion, the  work  done,  and  the  ailments  or  disorders  found 
among  the  school  children  of  these  cities,  especially  those 
of  the  elementary  schools.  In  this  chapter  it  becomes  our 
problem  to  set  forth  briefly  some  of  the  good  features  of 
these  various  medical  inspection  systems  which  are  some- 
what in  the  nature  of  departures  from  the  simple  inspection 
and  examinations  by  doctors  and  nurses.  Here  we  shall 
abandon  the  method  of  analyzing  the  data  strictly  by  cities, 
and  treat  the  problem  on  the  basis  of  topics  or  phases  em- 
phasized. Some  of  the  most  important  of  these  phases  are : 
the  methods  of  getting  treatments  and  the  starts  toward 
school  clinics,  the  various  preventive  methods  carried  on 
by  this  department,  the  examinations  of  children  for  work 
certificates,  and  the  various  more  or  less  scientific  investiga- 
tions of  the  work  carried  on  by  the  departments  themselves 
or  by  other  school  officials. 

I.  TREATMENTS  AND  SCHOOL  CLINICS 

The  special  methods  of  procuring  treatments  adopted 
by  medical  inspection  systems  in  these  cities  are  both  private 
and  public.  The  schools  carry  on  and  pay  for  certain  work, 
and  also  encourage  or  permit  a  good  deal,  but  not  enough, 
voluntary  assistance  by  private  organizations  and  individ- 
uals. The  ideal  towards  which  the  schools  seem  every- 
where to  be  directed  more  or  less  vaguely  is  that  of  a  first 
class  school  clinic  accessible  to  every  child  and  free  to  every 
child  who  wishes,  or  whose  parents  wish  him  to  take  advan- 
tage of  free  diagnosis  and  treatment,  with  the  further  pro- 

228 


PHASES  OF  MEDICAL  INSPECTION       229 

vision  that  every  child  in  a  school  system  must  either  pri- 
vately or  publicly  be  placed  in  good  physical  condition,  and 
that  there  can  be  no  escape  from  this  provision.  Com- 
pulsory  education  seems  absolutely  to  involve  com- 
pulsory health  and  the  most  economical  way  for  a  com- 
munity to  provide  adequate  diagnosis,  prevention  and  con- 
tinued or  immediate  treatment  is  through  the  instrumentality 
of  the  public  schools.  Why  the  schools  have  gone  so  long 
with  almost  utter  disregard  for  the  health  and  normal 
physical  development  of  their  compulsory  charges,  argues 
"a  certain  blindness  of  human  nature"  in  the  teaching 
profession.  This  blindness,  of  course,  which  is  almost  a 
physical  defect,  comes  naturally  out  of  the  excessive  isola- 
tion of  our  public  schools  and  teachers  from  the  real  life 
and  needs  of  our  people.  When  we  take  the  attitude  that 
the  problems  of  the  people  and  the  nation  set  the  problems 
for  the  public  schools,  then  we  shall  have  a  sensitive  adapta- 
tion of  our  educational  systems  to  the  real  life  of  the  times 
and  the  children  to  be  adapted. 

Some  of  the  essentials  of  adequate  school  clinics  seem 
to  be  the  following: 

1.  Convenience  to   the  pupils,   perhaps   for  the  most 

part  and  for  the  ordinary  cases,  in  every  school. 

2.  Several  divisions  in  the  charge  of  specialists  with 

nurse  assistants. 

3.  These  divisions,  for  a  beginning,  may  be: 

a.  Dental,  in  charge  of  dentists.  They  will  ex- 
amine the  cases  sent  in  by  nurses  and  doctors 
and  give  such  treatment  as  is  necessary,  and 
such  advice  for  dental  care  as  seems  desir- 
able, requesting  parents,  nurse,  and  teacher 
to  see  that  they  are  followed.  Small  charges 
may  be  made  where  they  seem  desirable, 
though  this  seems  as  unnecessary  as  volun- 
tary payment  for  the  free  text-books  and 
other  supplies  furnished  by  the  schools.  It 
is  as  much  the  advantage  of  the  state  to  have 


23o    SCHOOL  HEALTH  ADMINISTRATION 

children  in  good  health  as  it  is  to  have  them 
get  a  certain  amount  of  schooling.  And  the 
retarding  effect  of  the  various  ailments  may 
well  cause  such  waste  of  time  and  money 
as  to  pay  for  adequate  clinical  provisions. 

b.  Surgical,  in  charge  of  surgeons.     This  division 

will,  with  parents  present  as  much  as  pos- 
sible (and  parents  will  come  out  to  clinics 
when  they  will  not  come  to  mere  examina- 
tions), remove  such  adenoid  and  tonsillar 
tissues,  and  make  such  other  dressings  and 
simple  surgical  treatments  as  good  judgment 
provides.  Cases  of  strabismus  (cross-eye) 
and  defects  requiring  operative  treatment, 
may  well  be  handled  by  this  division. 

c.  Medical,  in  charge  of  regular  physicians.  This 

division  will  devote  itself  to  the  diagnosis  of 
referred  cases  of  many  ailments  not  falling 
to  other  divisions  and  the  giving  of  skilled 
treatments.  With  scalp  ringworm  cases 
needing  X-ray  treatment,  or  with  discharging 
ears,  favus  cases,  or  any  other  of  a  host  of 
ailments  which  cannot  adequately  be  handled 
by  the  nurses,  we  have  cases  for  this  division 
of  the  clinic.  The  Dunfermline  (Scotland) 
clinic  has  such  divisions  and  the  medical  di- 
vision reports  a  very  large  amount  of  work 
for  a  small  city  of  about  thirty  thousand 
population. 

d.  Ocular,    for    eyes    and    vision,    in    charge    of 

oculists.  This  division  will  handle  both  the 
treatment  of  eye  ailments  and  make  careful 
vision  tests  of  referred  cases,  furnishing 
either  prescriptions  alone  or  prescriptions 
with  the  proper  glasses.  Providence  has  al- 
ready entered  this  field  and  every  city  must 
undoubtedly  follow. 


PHASES  OF  MEDICAL  INSPECTION        231 

e.  Medical  gymnastics  division,  if  this  is  not  cor- 

related with  the  department  of  physical  edu- 
cation. 

f.  Psychological   division,    for   testing   backward 

children.* 

Practically  no  school  system  of  this  country  has  yet  a 
clinic  so  well  worked  out  and  so  paternal  as  this,  although 
there  are  a  number  of  approximations  to  it,  and  we  can 
see  scattered  over  the  country  its  various  elements.  We 
shall  begin  our  further  study  of  the  cities  with  the  various 
means  of: 

A.  Public  School  Treatments. 

The  work  of  the  nurses  consists  of  assisting  the  doctors 
at  examinations  and  making  vision  and  hearing  tests,  in- 
specting the  children,  visiting  the  homes  to  help  get  pre- 
ventive measures  and  treatments,  taking  the  children  to  free 
dispensaries  or  to  private  physicians,  and,  finally,  in  treating 
the  children  themselves. 

Physicians  are,  for  the  most  part,  prohibited  from  mak- 
ing treatments,  and  the  nurses'  work  in  the  field  of  treat- 
ment ranges  in  these  cities  from  almost  zero  up  to  the  large 
amount  of  work  done  in  Newark  and  a  few  other  cities.  In 
some  cities,  as  at  New  Haven,  all  the  medical  supplies  and 
instruments  were  carried  in  the  nurse's  bag,  and  consisted 
of: 

An  ear  syringe,  a  sponge,  some  bandages,  two  small 
basins,  combs  for  pediculosis,  bichloride  tablets,  olive  oil, 
zinc  ointment,  sulphur  ointment,  scissors,  tongue  depressors, 
and  a  graduated  glass. 

From  such  small  beginnings  and  less,  the  work  ranges 
upward  to  finely  equipped  medical  inspection  rooms,  or 
school  clinics,  in  many  or  most  of  the  school  buildings  and 
with  a  large  list  of  medical  supplies  kept  at  the  central  sup- 
ply department  and  furnished  to  schools  on  the  requisitions 
of  principals  along  with  other  school  supplies.  For  Boston, 

*Dr.  Cornell  suggests  other  divisions  in  his  book. 


23 2    SCHOOL  HEALTH  ADMINISTRATION 

the  requirements  for  a  medical  inspection  or  "nurse's  room" 
are  given  in  the  report  of  the  School-house  Commission, 
and  the  writer  got  further  details  at  first  hand.  The  plans 
for  the  room  and  the  equipment  are  much  the  same  as  those 
already  given  in  a  former  chapter  for  Summit.  The  same 
room  could  be  fitted  up  for  the  use  of  one  or  more  of  the 
above-mentioned  clinical  divisions,  of  course,  if  they  could 
work  at  different  times  of  the  week.  The  medical  inspec- 
tion cabinet  and  desk  combined  in  use  at  Boston  is  the  best 
seen,  but  a  better  one  was  found  by  the  writer  in  the  Depart- 
ment of  School  Buildings  in  the  City  of  New  York.  The 
latter  is  a  desk  cabinet,  with  two  doors  below,  and  drawers 
and  pigeon  holes  above  which  are  shut  up  and  covered  over 
by  a  glass  covered  door  which  lets  down  by  hinges  at  the 
bottom  and  makes  a  writing  desk.  The  top  of  the  cabinet 
is  covered  with  slate  to  keep  it,  like  the  top  of  the  desk, 
from  being  injured  by  chemicals  or  medicines. 

Most  cities  have  in  one  to  all  of  the  buildings  emer- 
gency medical  cabinets,  made  up  by  the  nurses  or  doctors, 
or  sold  complete  by  various  medical  supply  houses.  A  very 
small  one  found  in  New  Bedford  consisted  of  a  tin  box 
ten  inches  square  and  about  three  inches  deep  and  containing 
the  following: 

An  envelope  containing  scissors,  safety  pins,  and  pincers, 
a  handbook  of  first  aid  to  the  injured,  absorbent  cotton, 
gauze,  a  tourniquet,  a  package  of  bandages,  six  bandage 
rolls,  a  box  of  adhesive  plaster,  and  camphenol  ointment. 

Such  emergency  outfits  are,  of  course,  unnecessary  where 
the  same  materials  are  kept  in  an  adequate  medical  inspec- 
tion cabinet  in  each  medical  inspection  room  in  each  school. 

The  list  of  instruments  furnished  physicians  and  nurses 
vary  very  much.  In  Providence,  the  school  dentist  carries 
with  him  seventy-five  teeth  mirrors,  so  two  rooms  of  chil- 
dren can  be  examined  at  a  visit  without  any  disinfection  of 
mirrors.  Hoboken  has  perhaps  the  longest  list  of  medical 
tools  furnished  each  school,  and  the  entire  list  of  medical 
supplies  may  here  prove  interesting  and  suggestive: 


PHASES  OF  MEDICAL  INSPECTION        233 


1.  Jones'     platform     scale     with 

height  standard  attached. 

2.  Ear  speculum. 

3.  Nasal  speculum. 

4.  Head  mirror. 

5.  Teeth  mirror. 

6.  Tuning  fork. 


8.  Spirit  lamp. 

9.  Tape  measures. 

10.  Enamel  basins. 

11.  Tongue  depressors. 

12.  Applicators. 

13.  Absorbent  cotton. 


14.  Gauze. 

7.  Stop-watch,  one  for  each  physi-  15.  Gauze  bandages, 
cian.  1 6.  Lysol. 

Among  the  lists  found  in  other  cities  the  following  fur- 
ther  items  were   found: 


Rubber  gloves. 

Medicine  droppers. 

Forceps. 

Uniforms  for  nurses. 

Carrying  bags  for  nurses. 

Clinical  and  other  thermometers. 

Hair  brushes. 

Bath  caps. 

Tooth  picks. 

Graduate  glasses. 

Surgeon's  needles. 

Bandage  jars. 

Adhesive  plaster. 

Mercury  bichloride  tablets. 

Peroxide  of  hydrogen. 

Disinfectants,  sulphur  naphol,  etc. 

Green  soap. 

Boric  acid. 

Jamaica  ginger. 

Ammoniated  mercury. 

Creolin. 

Marigold  ointment. 

Witch  hazel. 

Chamois  skin. 

Tongue  depressor  handles. 

Vaccination  shields. 

Enameled  table  with  glass  shelves. 

Couches. 

Medical  cabinet. 

Chairs. 

Floor  mats,  rugs,  and  pillows 


Water  heaters. 

Paper  and  cloth  towels. 

Aromatic  spirits  of  ammonia. 

Collodian. 

Larkspur,  for  pediculosis. 

Kerosene,  for  pediculosis. 

Creasol,  for  pediculosis. 

Sulphur  ointment,  for  scabies. 

White  precipitate  ointment. 

Iodine. 

Sweet  oil. 

Wood  alcohol. 

Toothache  drops. 

Oil  of  cloves. 

Argyrol. 

Comp.  stearate  of  zinc. 

Vaselene. 

Comphenol. 

Adreniline. 

Powdered  chalk. 

Glycerine. 

Boric  acid  ointment. 

Vinegar,  for  pediculosis  nits. 

Vitagen. 

Alcohol. 

Muslin. 

Vision  test  charts. 

Tooth  brushes. 

Eye  glasses,  spectacles. 

Combs. 

Sterilizing  outfits. 


A  study  of  the  cost  of  all  these  items  was  made  in  each 
city,  and  comparisons  made.  Cities  that  have  tried  to  get 
along  by  buying  an  article  or  two  of  local  druggists  when- 
ever they  were  needed  have  wasted  a  good  deal  of  money. 
Twenty-five  cent  hair  brushes,  for  example,  have  been  sold 


234     SCHOOL  HEALTH  ADMINISTRATION 

for  $1.50  to  the  unsuspecting.  Changes  in  certain  cities 
have  since  been  made  along  these  lines  in  the  direction  of 
having  budgets  made  up  each  summer  for  the  following 
year,  and  then  the  lists  offered  for  bidders  from  anywhere. 
The  big  supply  houses  have  come  into  the  market  and  sold 
all  the  supplies  very  reasonably.  This  is  desirable  economy 
in  line  witji  other  business  improvements. 

A  list  of  the  medical  inspection  supplies  furnished  in 
quantities  at  Newark  is  here  appended: 

FOR  MEDICAL  INSPECTORS 

Absorbent  cotton,  Y2  pound  packages,  J.  &  J.  Red  Cross. 

Alcohol,  grain — 95  per  cent. 

Tongue  depressors,  in  packages  of  100. 

Bandages — 2-inch  by  10  yards,  J.  &  J.  Linton  gauze. 

Bichloride  of  mercury  tablets — 7^2  gr.  (100  tablets  in  a  bottle). 

Tincture  of  green  soap,  6-ounce  bottle. 

Glass  jar,  2-quart. 

Eleven  different  forms,  envelopes,  prescription  pads,  etc. 

FOR  SCHOOL  NURSES 

Absorbent  cotton,  K-pound  packages,  J.  &  J.  Red  Cross. 

Bandages,   i-inch  by  10  yards,  J.  &  J.  Linton  gauze. 

Bandages,  2-inch  by  10  yards,  J.  &  J.  Linton  gauze. 

Adhesive  plaster,  2-inch  by  10  yards,  J.  &  J.  "Z.  O." 

Alcohol,   grain — 95   per  cent. 

Plain  gauze,  I  yard  long,  I  yard  wide,  J.  &  J.  Red  Cross. 

Argyrol,  5  per  cent. 

Bichloride  tablets,  7^  grains. 

Flexible  collodian. 

Iodine,  tincture. 

Lysol. 

Sulphur  ointment. 

Sweet  oil. 

Stearate  of  zinc   (powder,  in  boxes). 

White  precipitate. 

Zinc  ointment. 

Bottles,  4-ounce,  with  corks. 

Ciliary  forceps,  No.  1628. 

Clinical  thermometer. 

Ointment  jars,  4-ounce. 

Tooth  picks. 

Three  blank  forms. 

FOR  PRINCIPALS 

Cotton,    bandages,    adhesive   plaster,    aromatic   spirits   of    ammonia, 
and  three  blank  forms,  reports  on  medical  inspection. 


PHASES  OF  MEDICAL  INSPECTION        235 

FOR  SANITARY  INSPECTOR 

Formaldehyde. 

Kerosene  oil. 

Alcohol,  wood. 

Cotton,  American  Beauty. 

Two  blank  forms,  one  a  report  of  sanitary  inspection  of  schools 
and  of  disinfection,  and  the  other  a  report  of  visits  to  the  homes  of 
quarantined  pupils. 

FOR  SUPERVISOR  OF  MEDICAL  INSPECTION 
Form  93,  a  permit  for  children  to  attend  school. 
Here  we  have  about  the  best  that  has  been  worked  out 
in  the  way  of  medical  inspection  supplies,  and  this  list  will 
probably  soon  be  added  to  if  the  efforts   for  a  first-class 
school  clinic  are  successful. 

PRESCRIPTIONS 

It  has  been  found  necessary  and  desirable  to  print  pre- 
scriptions in  the  various  languages  of  the  city  population  for 
a  rapidly  increasing  list  of  school  ailments.  Some  of  these 
are  at  present  for:  pediculosis  (lice),  ringworm,  impetigo, 
scabies,  caring  for  the  teeth  (tooth  powders),  and  home 
and  school  advice  which  amounts  to  prescriptions  for  a 
great  variety  of  other  ailments  of  a  simple  character.  We 
have  not  begun  to  discover  what  a  wide  field  of  health  edu- 
cation of  adults  exists  in  the  form  of  well  written  and  illus- 
trated pamphlets,  not  to  mention  lectures,  home-visits,  etc. 
A  very  valuable  book  for  home  treatment  and  prevention 
of  disease  has  been  written  by  Professor  N.  E.  Ditman, 
M.  D.,  of  Columbia  University,  entitled  "'Home  Hygiene 
and  Prevention  of  Disease"  (Duffield  &  Co.).  It  is  in  the 
form  of  a1  small  one-volume  cyclopedia,  beginning  with 
"Abscess"  and  ending  with  "Wry-neck,"  and  comprising 
very  practical  and  scientific  advice  on  practically  every  phase 
of  health  in  the  home.  I  wish  I  had  the  power  to  place 
it  in  the  hands  of  every  parent,  intelligent  enough  to  read 
the  newspapers,  in  America.  The  book,  of  course,  shows 
the  limitations  of  home  treatment  and  shows  also  where  the 
expert  skill  of  medical  men  is  necessary;  but  it  does  clear 
away  a  great  deal  of  the  superstition,  inscrutability,  and 


236     SCHOOL  HEALTH  ADMINISTRATION 

awesomeness  of  ill  health,  and  shows  plainly  and  simply 
each  individual's  responsibility  for  prevention  and  cure. 
Such  knowledge  is,  of  course,  essential  matter  for  our  high 
school  courses  in  hygiene,  but  the  pupils  there  do  not  get 
such  knowledge  or  acquaintanceship  with  such  book-tools, 
because  they  are  so  busy  cramming  comparatively  useless 
information. 

HEALTH   LECTURES 

A  new  departure  is  the  wide  range  of  simple  health 
lectures  being  given  in  many  cities.  Newark  has  four  or 
five  hundred  a  year,  given  by  specialists  or  persons  well 
qualified  to  speak,  on  a  great  variety  of  health  topics.  The 
nurses  and  doctors  also  give  a  great  number  of  health  talks 
to  the  children  and  teachers  of  the  schools.  Stereopticons, 
tuberculosis  exhibits,  dental  exhibits,  budget  exhibits,  and 
moving  pictures  all  are,  or  can,  be  enlisted  to  bring  to  the 
people  the  health  knowledge  which  is  essential  to  the 
saving  of  many  of  their  lives  or,  at  least,  conserving  and 
developing  their  efficiency  in  their  daily  work.  Denison's 
"Helping  School  Children"  (Harper's)  is  filled  with  sug- 
gestions for  promoting  the  health  of  the  school  children  and 
their  friends  and  relatives. 

SCHOOL  OCULISTS 

We  have  mentioned  the  school  oculists  at  Providence, 
and  the  splendid  work  they  are  doing  for  getting  scientific 
diagnoses  and  accurate  prescriptions  and  glasses  for  school 
children.  The  school  oculist  is  bound  to  come.  These  two 
oculists  at  Providence  give  "two  afternoons  a  week  at  the 
Fourth  Ward  Room  for  examining  eyes,"  for  which  they 
receive  an  annual  salary  of  $300.  Several  more  are  needed 
more  afternoons  a  week. 

SCHOOL  NEUROLOGISTS 

Providence  has  also  the  only  school  neurologist  in  this 
group  of  cities,  or  had  at  the  time  of  this  study,  1910-11. 
Neurologists  or  psychologists  for  testing  mental  defective- 


PHASES  OF  MEDICAL  INSPECTION        237 

ness  and  helping  with  the  education  of  backward  and  feeble- 
minded children  are,  however,  to  be  found  in  a  number  of 
cities  (e.  g.,  Cleveland  and  Los  Angeles)  in  the  United 
States.  Their  work  could  hardly  be  called  treatment  per- 
haps, but  they  are  naturally  mentioned  in  this  place. 

B.  Treatments  by  Private  Organizations 

The  great  field  for  private  health  assistance  to  the 
schools  has  been,  it  seems,  in  the  field  of  school  dentistry.* 
We  find  groups  or  associations  of  dentists  in  many  cities 
volunteering  their  services. 

The  following  cities  of  the  twenty-five  had  more  or  less 
of  such  voluntary  work  during  the  years  of  this  study: 
Summit,  Norwood,  Winchester,  Montclair,  Meriden,  Wa- 
terbury,  New  Bedford,  Trenton,  Cambridge,  Lowell, 
Rochester,  Newark,  and  Boston. 

In  Winchester,  the  dentists  have  a  schedule  of  half  days 
on  which  they  will  work  and  give  their  services,  with  nom- 
inal charge  of  twenty-five  cents  a  case.  In  Cambridge  and 
Waterbury  the  school  department  has  purchased  chairs  at, 
or  less  than,  $300  each,  which  are  taken  from  school  to 
school  as  needed.  In  New  Bedford,  the  Health  Depart- 
ment spent  $600  for  a  chair  and  other  equipment  for  a 
dental  room,  all  of  which  was  placed  at  the  disposal  of  the 
volunteer  dentists.  In  Trenton,  a  very  finely  equipped 
dental  suite  of  rooms  is  furnished  by  the  city  in  the  new 
city  hall.  Such  volunteer  work  goes  along  very  well  for  a 
time,  but  it  almost  invariably  breaks  down  unless  a  city 
responds  soon  and  takes  the  new  institution  over.  No  city 
at  this  late  day  really  needs  to  be  convinced  by  volunteer 
demonstration  of  the  necessity  of  such  clinics  or  divisions 
of  clinics.  The  experience  of  cities  the  world  over  is  at  the 
disposal  of  any  who  wish  to  meet  the  vital  health  problems 
of  the  people. 

In  Boston,  as  related,  the  new  Forsythe  Dental  Dis- 
pensary, left  as  a  private  bequest,  is  almost  extensive  enough 
to  handle  the  dental  problem  of  all  the  children  of  Boston 


*Providence  alone,  also,  had  a  school  dentist  employed  by  the  city. 


238      SCHOOL  HEALTH  ADMINISTRATION 

up  to  the  age  of  sixteen  years.  It  is  not  thought  that  existing 
dentists  will  suffer  by  such  an  arrangement.  Rather  they 
will  gain  through  an  adult  population  educated  in  the 
realization  of  the  value  of  good  dental  services.* 

Other  voluntary  forms  of  health  and  medical  .service  to 
children  are :  the  provision  of  clothing  brought  in  by  the 
children  and  distributed  by  the  nurses,  the  provision  of 
outings  on  private  bequests,  as  at  Brockton,  the  provision 
of  free  eye-glasses,  the  various  hospital  and  dispensary 
forms  of  treatment  offered  and  given  so  freely  and  gen- 
erously to  all  that  the  nurses  bring  or  send,  the  feeding  of 
the  undernourished,  the  open-air  schools,  and  a  great  host 
of  other  ways  almost  too  numerous  to  mention  but  springing 
into  being  wherever  the  school  officials  or  the  public  or  both 
together  are  genuinely  sensitive  to  the  health  needs  of  the 
actual  children  in  the  public  schools  and  homes. 

The  administrative  solution  of  the  problem  of  treatment 
is  to  organize  it,  get  it  into  the  hands  of  skilled  and  perma- 
nent workers,  and  to  make  the  private  work  become  public 
policy  as  soon  as  its  value  is  demonstrated,  thus  leaving  new 
fields  open  for  private  initiative.  School  superintendents 
frequently  do  not  see  very  clearly  the  health  needs  or  are  so 
engrossed  with  other  matters  that  they  have  no  time  for 
health  essentials.  This  and  a  number  of  difficulties  has  led 
the  writer  to  advocate  a  thorough  integration  of  all  health 
agencies  in  a  school  system,  in  one  department  of  hygiene, 
and  under  one  physician,  physical-educator,  or  educational 
hygienist,  who  will  be  responsible  for  the  health  and  normal 
physical  development  of  the  school  children.  The  divisions 
of  such  a  department  may  well  be,  as  before  stated,  and 
first  so  listed  by  Dr.  Woods,  I  believe:  Medical  Inspection, 
School  Sanitation,  the  Teaching  of  Hygiene,  Physical  Edu- 
cation, and  the  Hygiene  of  Teaching.  The  salary  for  such 
a  man  will  be  near  $3,000,  not  less;  but  ways  can  easily  be 
devised  in  many  cities  for  acquiring  him  with  little  extra 


*Such  dental  work  in  public  schools  will  be  found  well  treated  in 
Gulick  and  Ayres*  Medical  Inspection  of  Schools,  1913  edition,  and 
Cornell's  Health  and  Medical  Inspection  of  School  Children. 


PHASES  OF  MEDICAL  INSPECTION        239 

expense,  and  several  small  cities  can  go  together  to  get  one 
man  as  they  now  do  in  New  England  for  superintendents. 
In  the  country,  there  can  well  be  a  county,  or  township 
Director  of  Hygiene  who  can  examine  children,  direct 
nurses  and  assist  physicians,  and  promote  all  health  phases 
which  are  now  so  terribly  neglected  in  many  or  most  country 
schools.* 

II.    PREVENTION    IN    MEDICAL    INSPECTION 

The  principal  preventive  work  of  such  systems  is,  quite 
largely,  that  of  education,  finding  incipient  cases  of  all  kinds, 
the  provision  of  open-air  schools,  and  the  general  co-opera- 
tion with  or  the  correlation  of  all  phases  of  educational 
hygiene  above  mentioned. 

OPEN-AIR  SCHOOLS 

Open-air  schools  were  found  in  South  Manchester, 
Montclair,  Schenectady,  Cambridge,  Providence,  and  New- 
ark. Detailed  studies  of  the  administration,  cost,  equip- 
ment, methods  and  results  were  made  in  all  cases,  but  we 
cannot  here  go  into  the  matter  in  detail.  Readers  are  re- 
ferred to  the  excellent  reports  of  some  of  this  work  at  South 
Manchester,  Cambridge,  Providence,  and  Newark.  At 
Providence  the  work  is  in  charge  of  the  Board  of  Health 
and  its  enterprising  director,  Dr.  Chapin.  Reference  is  also 
necessarily  made  to  the  valuable  little  book  by  Dr.  L.  P. 
Ayres  on  the  subject. 

Open-air  schools  are  not  filled  with  tubercular  children 
as  many  suppose,  but  with  the  poorly  nourished,  the  anemic, 
the  delicate,  and  incipient  or  potential  cases  of  tuberculosis. 
The  advantages  lie  in  the  way  of  segregation  from  other 
pupils  of  the  schools,  of  special  adaptations  of  work  and 
regimen  to  individual  needs,  of  the  good,  fresh  air,  of 
special  loving  kindness  which  is  the  best  medicine  for  some 
children,  of  the  more  natural  motor  activity,  and,  especially, 
of  better  feeding  in  many  cases.  It  is  hard  to  regulate  the 
feeding  of  selected  children  in  a  big  school  system,  but  it  is 


*See  the  plan  for  such  work  in  the  last  chapter. 


240     SCHOOL  HEALTH  ADMINISTRATION 

easy  when  these  children  are  brought  together  in  segregated 
groups  and  all  participate  in  the  same  activities. 

Open-air  schools  are  not  expensive,  but  are  more  costly 
than  the  usual  school  system.  The  expense  is  an  added  one, 
because  many  or  most  of  the  children  leave  vacant  seats  in 
the  schools.  But  it  is  worth  all  that  is  spent  on  such  pro- 
visions for  three  reasons,  at  least : 

a.  It  shows  how  necessary  fresh  air  is  in  the  schools  and 
in  the  homes  for  all  children  and  all  adults.     It  gets  school 
officials  and  parents  to  thinking  of  how  to  provide  natural, 
"uncooked"  air  to  all  children  at  all  times.  It  shows  teachers 
that  they  do  not  have  to  live  in  a  torrid,  desert  atmosphere 
to  be  comfortable  and  happy.     It  shows  principals  and  jani- 
tors that  more  dependence  can  be  placed  upon  radiators  for 
heating  the  rooms  instead  of  raising  the  temperature  almost 
entirely  by  overheating  or  cooking  the  air  before  it  goes  into 
the  fans  and  the  ventilating  flues.     It  shows  that  moisture 
should  be  added,  perhaps  in  the  form  of  steam  pans,  and 
in  large  quantities,  and  adequately  registered  and  regulated 
by  accurate  humidometers,  keeping  the  air  at  about  55  per 
cent  saturation,  and  a  temperature  in  the  fan  room  of  about 
62    degrees    and    in    the   school    rooms    about    65    degrees 
Fahrenheit.  It  shows  the  value  of  open-window  rooms  where 
pupils  simply  keep  on  their  warm  wraps,  and  breathe  di- 
rectly the  outer  air,  without  recourse  to  an  elaborate  fan 
system.     But  this  leads  us  into  school  sanitation   in  these 
cities,  and  that  is  another  chapter. 

b.  It  shows  the  importance  of  nourishment  for  the  de- 
bilitated children,  and  a  fundamental  essential  for  all  chil- 
dren, besides  the  fresh  air. 

c.  The  cost  is  of  the  nature  of  a  stitch  in  time  saving 
nine.     Most  children   in  open-air  schools   that  have  been 
followed  up  carefully  for  some  time  after  such  a  school  has 
been  given  up  or  the  children  had  to  leave  the  school  (as  in 
the  case  of  the  lamented  Dr.  Arthur  T.  Cabot's  study  and 
follow-up  work  in  Boston)  have  either  died  in  early  life  or 
indicated  that  they  had  few  years  yet  to  live.     Long  con- 
tinued open-air  schooling  for  a  number  of  pupils  will  prob- 


PHASES  OF  MEDICAL  INSPECTION        241 

ably  raise  their  resistance  enough  to  make  their  span  of  life 
normal  and  save  to  society  all  the  expense  incurred  in  their 
upbringing.  The  work  can  probably  be  planned  so  such 
saving  to  the  school  system  alone  will  more  than  balance 
the  cost  of  open-air  schools. 

It  is  probable,  also,  that  properly  devised  systems  ot 
ventilation  in  the  regular  schools  and  proper  attention  to 
nourishment,  eradicating  the  coffee-habit,  etc.,  will  make  un- 
necessary any  elaborate  extension  of  such  schools.  It  may 
be  well  to  call  them  open-air  hospital  schools  and  provide 
them  for  only  a  few,  while  placing  the  greatest  emphasis  on 
adequately  caring  for  the  ninety-and-nine. 

MEDICAL  CONSULTATIONS   FOR  MOTHERS 

The  child-hygiene  departments  of  some  of  our  progres- 
sive boards  of  health  begin  their  care  of  children  with  con- 
ception and  follow  them  up  in  one  way  or  another  until  the 
age  of  the  work  certificate.  This  is  the  boast  of  Boston  and 
of  several  other  cities.  In  Newark,  the  school  medical 
inspection  department  has  provided  free  medical  consulta- 
tion for  mothers  with  infants  or  pre-school  children.  The 
development  of  this  work  and  the  good  results  which  have 
followed  show  that,  without  invading  the  fields  of  the  health 
department,  the  school  department,  through  its  medical  in- 
spection and  whole  hygiene  department,  can  help  to  insure 
the  efficiency  of  the  children  in  the  schools  long  before  they 
set  foot  in  even  the  kindergarten.  Such  extensions  in  re- 
sponse to  genuine  community  needs  can  in  the  long  run  be 
only  benificent,  regardless  of  the  croakings  of  the  wor- 
shippers of  the  god  of  things  as  they  were. 

SCHOOL  BUDGET  EXHIBITS 

For  educational  and  civic  purposes,  an  annual  budget 
exhibit  in  which  the  hygiene  department  of  the  schools  is 
represented,  may  be  of  very  great  value.  Hoboken  is  the 
only  city  having  had  such  an  exhibit  in  the  year  of  study, 
among  the  twenty-five  cities.  The  exhibits  consisted  of 
charts  showing  the  effects  of  various  ailments  on  school 


242     SCHOOL  HEALTH  ADMINISTRATION 

progress  a  la  Ayres,  the  number  of  children  affected  with 
various  ailments,  the  duties  of  the  parents  in  various  direc- 
tions, and  a  sample  of  each  kind  of  the  medical  supplies  on 
burlap  screens,  with  the  cost  of  each  below.  Those  desiring 
to  utilize  this  means  of  reaching  the  parents,  the  tax-payers 
and  the  children  may  well  correspond  with  the  New  York 
Bureau  of  Municipal  Research,  which  has  been  the  father 
of  the  movement. 

DISINFECTION  OF  SCHOOLS  AND  HOMES 
A  good  deal  of  money  is  spent  in  this  line  of  prevention 
of  the  spread  of  infectious  ailments.  Montclair  has  a  sys- 
tem of  sending  formaldehyde  gas  through  the  vents  of  the 
ventilating  system,  so  that  a  few  minutes  after  an  evening 
audience  has  used  a  school  auditorium,  for  instance,  the 
fumes  so  fill  the  room  that  it  is  impossible  for  a  person  to 
remain  in  it.  Costly  paintings  hung  on  the  walls  of  the 
auditorium  visited  there,  but  no  damage  to  them  or  to  any- 
thing else  seemed  to  follow.  However,  with  all  the  work 
and  expense,  the  value  of  such  disinfection  is  being  seriously 
questioned  by  medical  men.  The  dependence  upon  this 
mode  of  prevention  is  waning,  and  we  very  much  need 
such  studies  as  those  of  Dr.  Chapin  of  the  Providence  Board 
of  Health,  those  of  Kerr  in  London,  and  of  Professor 
Jordan  of  the  University  of  Chicago.* 

EXAMINATIONS  FOR  WORK  CERTIFICATES 
A  number  of  the  cities  are  coming  to  a  realization  of 
the  importance  of  seeing  that  every  child,  requesting  a  work 
certificate  at  the  age  of  fourteen,  is  guarded  from  going  into 
the  struggle  of  employment  with  a  poor  health  equipment. 
Such  medical  examinations  by  Boards  of  Health  or  Boards 
of  Education  frequently  get  treatments  where  all  former 
efforts  have  failed,  and  in  some  cases  for  the  first  time  dis- 
cover defects  that  will  prove  a  serious  handicap  unless  prop- 
erly corrected.  Boston  seemed  to  be  doing  most  in  this 


*See  reports,  and  the  1912  N.  E.  A.  volume,  article  by  Professor 
Jordan  giving  many  references,  and  bringing  up  a  number  of  these  cor- 
related problems  of  school  infection. 


PHASES  OF  MEDICAL  INSPECTION        243 

field  in  the  year  of  the  study,  and  the  writer  learned  much 
about  the  work  by  watching  the  examinations,  and  talking 
with  the  examiners  afterwards.  In  only  rare  cases  has  it 
been  necessary  to  refuse  such  certificates  although  many  are 
postponed  for  a  time. 

Adequate  vocational  guidance  will  of  course,  in  each 
school  system,  take  this  health  matter  into  consideration, 
relieving  the  health  department  of  the  obligation.  Adequate 
medical  inspection  throughout  school  life  will  greatly  lessen 
the  need  for  such  service,  as  a  special  piece  of  medical  work. 
This  of  course  argues  power  of  compulsion  in  the  lower 
grades,  and  this  is  what  the  New  Jersey  law  grants  and 
many  cities  in  one  way  or  another  enforce — that  parents 
may  be  compelled  to  place  the  child  in  good  health  condi- 
tion, or  permit  the  school  authorities  to  do  so.  Courts, 
truant  officers,  and  cruelty  to  children  societies  all  work 
together  for  the  benefit  of  the  child  where  any  parent  or 
guardian  is  stubborn  in  his  ignorance. 

HEALTH    INVESTIGATIONS    BY    DEPARTMENTS    OF    MEDICAL 

INSPECTION 

The  work  of  medical  inspection  and  all  health  work 
must  be  placed  upon  an  adequate  scientific  basis,  commensu- 
rate with  the  newer  sciences  of  medicine  and  education.  A 
city  that  does  not  or  cannot  adequately  and  accurately  meas- 
ure results  in  this  field  is  condemned  at  the  start. 

Very  few  cities  have  made  anything  like  scientific  inves- 
tigations of  what  was  being  accomplished,  what  ought  to 
be  accomplished,  or  what  was  necessary  to  do  the  work. 
Boston  probably  made  more  investigations  during  the  years 
studied  than  all  the  other  cities  put  together.  If  this  volume 
does  nothing  else  but  show  that  there  are  an  immense 
number  of  problems  in  educational  hygiene  which  demand 
immediate  solution  by  careful  inductive  methods,  its  exist- 
ence will  have  been  justified. 

Some  of  the  problems  investigated  in  Boston  were: 

i.  The  relation  of  temperature  of  school  rooms  to  the 
number  of  cases  of  anemia  found  in  the  rooms. 


244     SCHOOL  HEALTH  ADMINISTRATION 

2.  The  relations  of  ill-health  and  physical  defects  to 
retardation. 

3.  The  ventilation  and  temperature  of  school  rooms. 

4.  A  study  of  5,000  choreic  children,  and  their  school 
progress. 

5.  An  investigation  of  the  number  of  tubercular  chil- 
dren in  the  schools,  and  their  environments. 

6.  A  study  of  the  number  of  cases  of  defective  vision 
and  hearing  in  the  schools,  and  the  number  of  children  wear- 
ing glasses,  etc. 

These  and  other  studies  were  made  by  this  one  city. 
Unfortunately  none  of  the  studies  was  carried  through  to 
completion  by  the  use  of  such  rigorous  inductive  methods 
as  would  insure  accurate  and  comparable  results,  so  the 
results  of  the  findings  are  not  here  quoted.  They  were 
regarded  as  starts  only  in  the  right  direction,  and  have  not 
all  been  published  by  the  school  authorities  in  public  jour- 
nals, although  mention  of  some  of  them  can  be  found  in 
the  Annual  Report  of  the  School  Committee  for  1910. 

The  same  could  be  said  for  the  studies  of  the  relation- 
ship of  ill-health  to  retardation  in  South  Manchester,  Brock- 
ton, Mt.  Vernon,  Schenectady,  Hoboken,  and  elsewhere. 
The  field  is  so  new  and  the  problems  are  so  complex  and 
the  requirements  of  adequate  investigation  are  so  great  in 
the  way  of  time,  labor  and  ability,  or  special  technique,  as 
well  as  a  number  of  years  of  study  of  results,  that  we  have 
as  yet  little  definite  knowledge  of  this  health  work  in  the 
schools.  And  yet  there  is  promise  in  every  study,  valuable 
data  possibly  to  lay  by,  certain  tendencies  showing  them- 
selves, and  certain  skill  and  interests  arising  in  the  investi- 
gators which  are  the  things  to  be  prayed  for  if  we  are  to 
get  a  science  of  educational  hygiene  or  a  science  of  educa- 
tion. We  can  close  this  section  with  no  finer  thoughts  than 
those  expressed  by  Dr.  Cruickshank,  now  Director  of 
Hygiene  for  the  Board  of  Education  of  Scotland  in  his 


PHASES  OF  MEDICAL  INSPECTION        245 

1911-12  report  of  medical  inspection  in  Dunfermline,  Scot- 
land:* 

"It  behooves  them  (the  Trustees)  to  renew  their  inter- 
est and  redouble  their  energies  in  seeking  to  establish  thor- 
ough and  scientific  methods  of  investigation  into  the  prob- 
lems which  bear  upon  the  numerous  ailments  and  nutritional 
deficiencies  of  the  school  children  of  their  town.  It  has  to 
be  borne  in  mind  that  this  work  is  scientific  in  the  highest 
sense  of  the  term ;  that  it  can  be  done  only  by  those  who  have 
the  necessary  scientific  training;  that  it  entails  much  diffi- 
cult and  accurate  work,  and  that  the  results  cannot  be  made 
immediately  apparent,  as  is  the  case  with  the  effects  of 
treatment.  It  is,  of  course,  essential  that  scientific  investiga- 
tion should  both  precede  and  accompany  scientific  preven- 
tion. The  days  of  empiricism  in  medical  science  are  over, 
and  no  true  progress  can  be  made  in  the  applications  of 
medical  science  to  the  problems  of  education  unless  their 
points  of  contact  are  subjected  to  minute  and  accurate  in- 
vestigation. In  all  probability  medical  science,  more  than 
any  other,  will  exert  an  influence  on  future  educational 
movements." 

BOARD  OF  HEALTH  VS.  BOARD  OF  EDUCATION  ADMINIS- 
TRATION 

Our  data  are  too  inaccurate  and  too  narrow  in  scope  to 
permit  any  conclusive  statement  as  whether  the  boards  of 
education  or  the  boards  of  health  should,  in  general,  have 
charge  of  school  medical  inspection.  As  we  have  gone 
through  the  various  phases  of  medical  inspection  efficiency, 
we  have  found  a  number  of  instances  where  in  essential  mat- 
ters the  boards  of  health,  even  though  they  are  much  older 
in  the  work,  on  the  average,  fall  decidedly  below  the  effi- 
ciency of  the  boards  of  education.  We  have  attempted  to 
get  data  on  enough  items  by  which  to  rate  the  various  cities 


*The  writer  has  recently  distributed  100  copies  of  this  excellent  re- 
port bound  in  boards  free  of  charge  to  persons  in  this  country  known 
to  be  interested  in  school  health  and  working  for  it,  and  a  thousand 
more  have  been  promised  by  Mr.  Andrew  Carnegie. 


246     SCHOOL  HEALTH  ADMINISTRATION 

and  the  separate  divisions  in  Boston  and  New  Bedford 
where  both  bodies  participate.  Some  of  the  most  essential 
data  we  could  not  get,  so  the  table  showing  the  relative 
ranking  of  the  cities  is  merely  suggestive  of  a  method.  It  is, 
however,  interesting  to  see  how  the  boards  of  health  place 
themselves  at  the  bottom  of  the  list  in  the  efficiency  series. 
My  judgment  of  the  probable  true  ranking  of  the  cities  on 
all  items,  i.  e.,  on  their  general  efficiency,  need  not  be  ac- 
cepted.* My  best  judgment  is,  however,  that,  with  perfect 
records  and  accurate  efficiency  ratings  for  all  elements,  the 
ranks  of  any  one  of  these  cities  would  not  be  raised  or  low- 
ered more  than  five  points  in  the  twenty-five.  The  hardest 
problem  in  the  ranking  was  to  get  and  decide  upon  what  were 
real  efficiency  data,  and  the  next  hardest  problem  was  the 
relative  place  of  Summit  and  Newark.  The  weakness  of 
the  latter  was  in  the  entirely  insufficient  number  of  nurses 
in  comparison  with  the  number  of  physicians,  and  lack  of 
provision  for  high  school  inspection,  while  Summit  was 
weak  in  records  and  used  up  a  large  share  of  the  nurse's 
time  for  the  work  of  attendance  officer,  though  the  latter 
is  to  be  commended  in  general  even  if  it  isn't  strictly  health 
work.  Definite  steps  have  since  been  taken  in  Newark  to 
reverse  the  numbers  of  doctors  (38)  and  nurses  (8),  with 
the  doctors  'to  be  district  supervisors  only,  while  the  high 
schools  are  now  pretty  well  cared  for  by  male  and  female 
doctors,  with  nurses. 

The  medical  officers  of  boards  of  health  are,  of  course, 
jealous  of  their  powers,  and  will  not  agree  with  my  opinion, 
nor  with  my  data,  perhaps.  A  good  example  of  their  point 
of  view  is  given  in  the  April,  1913,  American  Journal  of 
Public  Health  in  the  Report  of  the  Committee  on  Medical 
Inspection  of  Schools  and  School  Children,  Dr.  S.  H. 
Durgin,  probably  the  first  regular  school  medical  inspector 
of  the  United  States,  of  Boston,  as  chairman,  and  Dr.  G.  F. 
Kiefer,  of  Detroit,  as  acting  chairman.  They  make  a  strong 
stand  for  board  of  health  control,  but  present  no  data  in 
proof  and  practically  no  arguments.  On  other  points,  their 

*See  page  254  for  a  tentative  ranking  of  the  cities  on  several 
obtainable  items. 


PHASES  OF  MEDICAL  INSPECTION        247 

conclusions,  based  partly  on  a  questionnaire,  agree  very 
markedly  with  conclusions  already  published  by  the  writer. 

The  general  impression  which  one  gets  in  going  about 
from  city  to  city  and  studying  the  work  of  both  departments 
is  unstatistical  but  impressive  to  the  one  experiencing  it.  On 
the  whole  there  is  marked  contrast  in  efficiency,  with  sev- 
eral exceptions,  between  the  two  departments,  in  favor  of 
the  boards  of  education.  Politics  plays  a  larger  part  in  the 
work  of  most  health  boards,  and  this  seems  to  vitiate  much 
of  their  endeavor. 

To  summarize  many  scattered  points  we  give  below  some 
of  the  chief: 

ADVANTAGES    AND    DISADVANTAGES    OF    BOARD    OF    EDUCA- 
TION AND  BOARD  OF   HEALTH  ADMINISTRATION 
OF  MEDICAL  INSPECTION 
I.   BOARDS  OF   HEALTH 

A.  Advantages. 

1.  They  can,  if  efficient,  knit  up  school  health  with  the 

general  health  problem. 

2.  They  can  medically  inspect  parochial  and  private 

school  pupils  as  well  as  public  school  pupils.  This 
Boards  of  Education  can  do  only  where  state  laws 
laws  force  parochial  schools  to  obtain  adequate 
medical  inspection.  It  is  then  relatively  easy,  as 
in  Milwaukee,  for  the  boards  of  education  to 
get  control  of  this  important  service. 

3.  They  can  employ  medical  inspectors  on   full-time, 

giving  them  other  public  health  work  during  a 
large  part  of  the  time. 

4.  They  can  keep  physicians  and  nurses  in  touch  with 

all  phases  of  the  health  problem  in  the  city  and 
community,  by  having  them  share  in  the  work  of 
infant-mortality  education  in  the  summer,  district 
nursing  of  adults,  infectious  disease  quaran- 
tine, etc. 

5.  Where  there  is  an  efficient,  interested  superintendent 

of  health,  not  too  much  engrossed  with  other 
health  matters,  there  is  a  possibility  of  more  ex- 
pert supervision  of  school  doctors  and  nurses,  and 


248     SCHOOL  HEALTH  ADMINISTRATION 

more  progress  toward  a  wide  range  of  curative 
and  preventive  measures,  than  in  a  school  system 
where  the  school  superintendent  has  no  medical 
specialist  as  supervisor  of  educational  hygiene  or 
of  medical  inspection,  and  is  himself  little  inter- 
ested or  learned  in  school  hygiene. 

B.  Disadvantages. 

1.  They  seem  to  be  more  under  the  dominance  of  par- 

tizan  politics,  and  not  as  efficient  as  are  the  boards 
of  education. 

2.  They    introduce    an    extraneous    element    into    the 

schools,  making  it  impossible  to  get  the  best  kind 
of  co-operation  on  the  part  of  teachers  and  prin- 
cipals in  health  work. 

3.  They  make  impossible  the  organization  of  all  the 

five  divisions  of  educational  hygiene  into  one  or- 
ganic department. 

4.  They  do  not  seem  to  get  the  money  and  the  support 

for  medical  inspection,  as  well  as  do  the  boards  of 
education. 

5.  They  look  upon  the  school  health  work  in  a  more 

limited  way,  generally,  e.  g.,  from  the  standpoint 
of  infectious  diseases,  or  merely  that  of  finding 
the  ailments  of  children.  Curative  and  preventive 
measures,  and  the  treatment  of  the  child,  his 
health  and  his  education,  as  a  whole  can  hardly  be 
obtained,  and  are  little  emphasized  by  such  boards. 

6.  They  seern^  to  be  weaker  in  the  way  of  educating 

the  parents  through  school  meetings,  medical  in- 
spection, pamphlets,  etc. 

7.  They  very  largely  omit  complete  physical  examina- 

tions of  the  children. 

8.  They  are  especially  weak  in  providing  an  adequate 

number  of  school  nurses,  in  comparison  with 
boards  of  education.  Counting  Boston  and  New 
Bedford,  and  leaving  off  the  first  three  of  our 
cities,  making  1 1  boards  of  education  and  1 1 
boards  of  health  participating  in  this  work,  we 


PHASES  OF  MEDICAL  INSPECTION        249 

find  the  sum  of  the  nurses  for  the  boards  of  educa- 
tion is  59,  while  the  sum  for  the  boards  of  health 
is  only  16.  Boston  now  has  over  forty  nurses  and 
other  boards  of  education  have  been  increasing 
their  numbers.  The  ratio  now  would  show  a 
greater  disparity.  Our  cities  do  not  well  show 
this  tendency  because  they  were  selected  on  the 
basis  of  their  having  nurses.  In  proportion  to  the 
number  of  pupils  and  using  the  data  for  the  entire 
country  given  by  the  Sage  Foundation  we  should 
have  a  far  greater  disparity.  The  Boards  of 
Health  Committee,  above  mentioned,  strongly 
urges  the  use  of  school  nurses,  however,  and  rec- 
ommends as  many  as  three  nurses  for  each  doctor, 
and,  at  least,  one  for  each  1,500  to  2,000  pupils, 
and  only  one  physician  for  each  3,000  pupils, 
where  he  gives  only  part  time  to  the  work  as  they 
recommend  further. 

9.  The  best  types  of  medical  inspection  records,  re- 
ports, and  statistics  are  being  devised  by  boards  of 
education  and  they  are  using  nomenclature  that  is 
more  easily  understood  by  the  people  to  whom 
reports  are  made  than  those  made  by  boards  of 
health.  However,  in  these  cities  we  find  in  two 
places  the  ailments  of  children  given  in  greater 
detail  and  in  better  organized  form,  than  is  the 
case  with  most  of  our  board  of  education  reports. 
Cleveland  and  Newark,  on  the  board  of  education 
side,  and  Providence  and  Boston  on  the  board  of 
health  side  would  stand  out  in  this  one  particular. 
10.  Board  of  health  administration  of  school  medical 
inspection  is  contrary  to  the  tendencies  of  the 
times,  most  cities  taking  up  the  work  in  recent 
years  putting  it  into  the  hands  of  the  school  offi- 
cials, and  whole  states,  with  the  unfortunate  ex- 
ception of  Minnesota,  going  in  this  direction,  e.  g., 
New  Jersey.  The  problem  evidently  will  soon  be 
a  dead  issue  except  for  scattered  cities  in  the  east 


250     SCHOOL  HEALTH  ADMINISTRATION 

When  states  get  general  directors  or  Supervisors 
of  (Educational)  Hygiene,  as  many  soon  will,  we 
shall  have  the  agencies  in  the  school  departments 
to  make  board  of  health  administration  unneces- 
sary anywhere. 

II.   BOARDS  OF   EDUCATION 

A.  Advantages. 

1.  The  work  can  be  done  by  boards  of  education  with- 

out loss  to  them  or  to  the  boards  of  health  and 
without  as  great  waste  of  public  expenditure.  The 
boards  of  education  can  supervise  the  health  con- 
ditions while  individuals  are  immature  and  in  pub- 
lic schools  with  good  means  of  control.  Boards 
of  health  can  do  the  same  for  individuals  in  pri- 
vate life;  and,  according  to  Winslow,  in  his  excel- 
lent article  in  the  June,  1913,  North  American 
Review,  this  will  soon  be  extended  to  factories 
and  other  institutions  where  individuals  congre- 
gate. In  this  article  also,  "Efficiency  in  the  Pub- 
lic Health  Campaign,'*  the  day  is  foretold  when 
most  if  not  all  medical  work  will  be  public  and 
not  private  work.  This  tendency  will  add  so  much 
to  the  boards  of  health  that  the  work  of  the 
schools  will  not  seem  so  large  in  comparison. 

2.  Our  data  seem  to  show  that,  in  general,  these,  and 

perhaps  most,  boards  of  education  take  up  this 
work  with  more  energy  and  general  efficiency, 
with  marked  exceptions,  of  course. 

3.  The  work  can  be  integrated  with  both  the  scholastic 

and  the  general  physical  development  of  the  pupils 
better  when  in  the  hands  of  one  board,  the  board 
of  education  necessarily,  than  when  the  work  is 
divided  up.  Schools  must  discover  their  own 
health  needs  in  order  to  do  away  with  the  present 
isolation  of  parts  and  to  go  about  physical  educa- 
tion, school  sanitation,  etc.,  in  a  rational  manner. 

4.  The  work  can  be  done  more  cheaply  to  the  city,  not 


PHASES  OF  MEDICAL  INSPECTION        25 1 

only  because  of  the  greater  efficiency  of  boards  of 
education  but  because  the  introduction  of  super- 
visors of  hygiene  as  herein  planned  will  make  pos- 
sible several  economies  and  the  avoidance  of  need- 
less duplication  of  efforts  by  the  two  boards. 

5.  As  is  now  done  in  New  Jersey,  boards  of  health 

can  medically  inspect  parochial  and  private 
schools,  leaving  to  the  boards  of  education  the  in- 
spection in  public  schools.  Whether  boards  of 
education  should  take  over  the  inspection .  in 
these  outside  schools  is  a  question.  France  and 
Germany  exercise  a  great  deal  of  control  over 
such  institutions,  making  them  conform  to  general 
state  requirements,  and  it  will  undoubtedly  be 
necessary  to  place  the  inspection  of  all  school  chil- 
dren in  the  hands  of  the  public  educational 
authorities. 

6.  Boards  of  education  seem  to  get  better  support  from 

the  public,  although  they  do  not  have  the  powers 
over  the  people  in  general  held  by  boards  of 
health.  The  schools  are  closer  to  the  public  purse 
and  will  be  more  apt  to  make  the  work  progress 
as  it  should. 

8.  They   emphasize   the   ailments   which,    though   not 

directly  or  immediately  death  dealing,  are,  never- 
theless, very  serious  in  their  effects,  and  yet  are 
largely  neglected  by  boards  of  health. 

9.  The   number   of  part-time   doctors   with   no    other 

school  health  work  can  be  greatly  reduced.  Super- 
visors of  hygiene  and  more  nurses  will  help  solve 
the  problem,  and  the  time  will  soon  come  when 
the  entire  medical  force  in  the  schools  will  in  some 
way  be  made  full-time  workers  like  the  teachers. 
Physical  education  and  departmental  teaching  of 
hygiene  may  be  mentioned  as  probable  occupation 
for  the  time  not  spent  in  physical  examination 
each  day.  With  a  morning  of  three  hours  daily 
for  medical  inspection  and  examination  this  would 


252     SCHOOL  HEALTH  ADMINISTRATION 

leave  only  the  short  afternoons  to  provide  for. 
Educational  hygiene  courses,  abridging  the  long 
M.  D.  preparation  and  physical  education  train- 
ing, may  make  possible  the  introduction  of  such 
men  at  salaries  around  $1,800  to  $2,000.  Full- 
time workers  are  undoubtedly  to  be  desired, 
though  we  have  no  data  with  which  to  prove  it. 
B.  Disadvantages. 

1.  At  present,  lack  of  competent  medical  supervision 

of  the  work  of  doctors  and  nurses. 

2.  Lack  of  control  over  parochial  schools,  with  the  pos- 

sibility of  uncontrolled  infection  in  these  schools 
spreading  to  the  public  schools. 

3.  Lack  of  correlation  with  the  general  health  prob- 

lems of  the  community  such  as  the  control  of  mid- 
wives,  milk  and  water  purity,  infant  mortality, 
tuberculosis,  infectious  diseases,  and  general  extra- 
school  health  difficulties. 

4.  Lack  of  sufficient  police  and  compulsory  power  in 

forcing  parents  and  guardians  to  place  their  chil- 
dren in  reasonable  health  condition  for  school 
attendance,  in  most  places. 

5.  Possibility  of  under-emphasis  of  the  health  factor 

by  an  institution  traditionally  specialized  for 
mental  and  scholastic  development. 

GENERAL 

In  general,  we  conclude  that  while  for  the  present  there 
are  a  number  of  cities  where  this  work  is  now  in  the  hands 
of  excellent  men,  such  as  Dr.  Chapin  of  Providence,  and 
may  well  remain  there  for  a  time,  and  while  it  is  desirable 
for  cities,  rural  communities,  and  states  to  keep  the  work 
in  the  hands  of  boards  of  health  for  the  benefits  of  variety 
and  testing  of  these  suggestions,  still,  for  the  most  part,  and 
for  all  cities  and  states  taking  up  the  work  for  the  first  time, 
and  for  any  localities  where  it  seems  quite  evident  that  the 
work  should  be  taken  out  of  the  hands  of  the  boards  of 
health, — in  all  these  places,  the  administrators  of  medical 
inspection  of  public  schools  should  be  the  boards  of  educa- 
tion. 


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254 

PHASES  OF  MEDICAL  INSPECTION       255 

MEDICAL  SUPERVISION  OF  HIGH   SCHOOL  PUPILS 

As  before  mentioned,  the  health  of  high  school  pupils  is 
very  much  neglected  and  this  part  of  our  school  system  is 
yet  very  much  of  a  mere  intellectual  and  academic  machine, 
running  by  mediaeval  and  formal-discipline  formulae.  In 
preparing  the  section  on  The  Hygiene  of  the  High  School 
for  Professor  Johnston's  new  book  on  High  School  Educa- 
tion, Volume  Two,  Scribner's,  the  author  has  been  interested 
to  go  more  deeply  into  the  health  problem  of  the  high 
school.  As  I  show  there,  the  best  data  obtainable,  from 
Newark  and  from  Washington,  D.  C.,  as  well  as  from  my 
study  in  Montclair,  disclose  the  fact  that  there  is  a  surpris- 
ing amount  of  sickness  and  physical  defectiveness  in  the  high 
school  population.  Carrying  through  the  fifty-four  classes 
of  ailments,  summarized  as  to  frequencies  among  a  thousand 
elementary  pupils  in  the  last  chapter,  we  find  that  the  high 
school  figures  are  close  up  to  those  for  elementary  pupils. 
We  are  by  them  reminded  of  G.  Stanley  Hall's  statement 
in  his  volumes  on  Adolescence  that  the  high  school  period  is 
a  period  of  a  low  death  rate  but  of  a  high  morbidity,  or  * 
sickness,  physical  defectiveness,  rate. 

Our  high  school  pupils  are  to  be  the  leaders  in  their 
respective  communities  and  they  should  be  fitted  for  efficient 
leadership  by  adequate  health  protection  and  education  while 
in  school.  Nothing  less  that  careful,  scientific  and  rigid 
medical  supervision  will  ever  show  our  high  school  teachers, 
too,  that  pupils  of  this  age  are  other  than  disembodied  men- 
talities and  book-reading  machines. 

I  have  called  attention  to  valuable  statistics  on  this  prob- 
lem in  Professor  Johnston's  volume.  I  give  here  the  results 
of  work  done  by  Dr.  Thos.  Storey  with  the  young  men  in 
the  secondary  and  lower  collegiate  departments  at  the  Col- 
lege of  the  City  of  New  York,  reprinted  from  the  Pedagogi- 
cal Seminary  for  December,  1912.  Dr.  Storey  has  also 
shown  by  his  records  that  such  medical  inspection  and  ex- 
amination does  not  throw  an  excessive  burden  upon  the  free 
dispensaries  and  clinics  but  furnished  in  the  year  ending 


256     SCHOOL  HEALTH  ADMINISTRATION 

June,  1911,  patients  for  1,100  professional  men  who  re- 
ceived over  $12,000  compensation.  (See  the  Proceedings 
of  the  Sixth  Congress  of  the  American  School  Hygiene 
Association.) 

RESULTS  OF  DR.  STOREY'S  FOLLOW-UP  SYSTEM  OF  MEDICAL 
INSPECTION  OF  HIGH  SCHOOL  STUDENTS 

The  success  of  this  "follow-up"  system  during  the  year 
ending;  June  i,  1912,  may  be  seen  in  the  following  statistics: 

ist  term    2d  term 

Number  of  boys  given  instructional  advice 1051  936 

Number  of  diagnoses  followed  up 1542  1409 

Number  of  conferences  necessary  to  follow  up  all  cases.  2244  1925 

Number  of  "diagnoses"  recorded  as  "under  treatment".  73  158 
Number  of  "diagnoses"  recorded  as  having  "secured 

treatment"    1298  1093 

Number    of    "diagnoses"    recorded    as    having    "refused 

treatment"    1 1  10 

Number   of   "diagnoses"    recorded    as   having   "promised 

treatment"    108  102 

Left  college   48  40 

Number  of  parents  refusing  to  secure  treatment 9  8 

Number  of  individuals  warned 328  290 

Number  of  individuals  debarred 71  92 

Number  of  individuals   reinstated 67  85 

Number  of  individuals  that  remained  debarred 4  7 

Number  of  dentists  consulted  privately 273  256 

Number  of  physicians  consulted  privately 189  139 

Number  of  opticians  consulted  privately 22  16 

Number  of  dental  clinics  attended 3  4 

Number  of  hospitals  attended 24  14 

Number  of  students  securing  private  dental  service 320  310 

Number  of  students  securing  private  medical  service...  204  147 

Number  of  students  securing  the  service  of  opticians. ...  15  1 8 

Number  of  students  securing  free  dental  service 8  13 

Number  of  students  securing  free  medical  service 4  5 

Number     of     students     securing     free     clinical     service 

(dental)     o  3 

Number     of     students     securing     free     clinical     service 

(medical)    10  II 

Number  of  students  securing  service  of  optician  free...  o  O 

Total  number  securing  private  service 539  475 

Total  number  securing  free  service 22  32 

Total  number  for  whom  home  treatment  was  sufficient.  490  429 
These  statistics  justify  the  following  conclusions: 
First.     Our  medical  inspection  is  effective.     It  is  securing  the  repair 
of  physical  defects,   and  it   is  correcting  unhygienic  conditions  in   over 


PHASES  OF  MEDICAL  INSPECTION       257 

ninety  per  cent  of  the  cases  in  which  such  treatment  is  desirable.  This 
plan  of  individual  instruction  in  personal  hygiene  is  improving  the 
physiological  efficiency  of  at  least  a  thousand  boys  every  half  year. 

Second.  Our  plan  of  individual  instruction  in  personal  hygiene  has 
met  with  the  support  of  the  parents  of  practically  all  our  boys.  Less 
than  one  per  cent  of  the  parents  refuse  treatment.  No  system  can 
endure  without  such  support. 

Third.  It  is  safe  to  expect  that  this  continued  personal  relationship 
extending  throughout  the  high  school  period  and  covering  the  first  two 
collegiate  years  will  develop  permanent  habits  of  personal  health  con- 
trol in  many  if  not  in  most  of  the  boys  under  our  supervision. 

GENERAL    CONCLUSIONS    REGARDING    MEDICAL    INSPECTION 

I.  The  administration  of  medical  inspection  in  these 
twenty-five  cities  is  extremely  variable  and  yet  there  are  evi- 
dences of  certain  norms  or  standards  toward  which  progres* 
sive  school  systems  are  more  or  less  slowly  evolving.  The 
problem  of  the  dissertation  is  to  discover  these  standards 
and  to  develop  others,  more  scientific  and  sociological,  in 
order  that  conscious  evolution  may  soundly  abridge  much  of 
the  tedious  process  of  hit  and  miss,  and  avoid  great  indi- 
vidual and  social  waste.  This  heterogeneity  is  shown  in  a 
variety  of  ways,  not  as  an  intensive  study  of  any  narrow 
phase  but  sweepingly  in  the  nature  of  a  broad  survey  in  ac- 
cordance with  the  nature  of  the  entire  study. 

A.  The  size  of  the  city  has  little  to  do  with  the  number 
of  medical  inspection  agents,  although  the  two  largest  cities 
in  a  number  of  particulars  have  almost  the  same  propor- 
tionate number  of  units,  doctors  and  nurses,  as  the  smallest 
cities. 

B.  To  enable  comparison  among  cities  as  to  number  of 
working  units  of  medical  inspection  forces,  the   following 
factors  were  added  together  for  a  unit:     Physicians:  aver- 
age number  of  hours  a  day,  average  number  of  days  a  week, 
average  number  of  weeks  in  the  year,  average  number  of 
hours   yearly   actually   employed   in   school  medical   work, 
including  clerical  work,  plus  the  nurse.     The  quality  of  the 
work  and  the  standing  of  the  physicians  in  their  profession, 
as  well  as  the  amount  of  school  time  spent  in  making  out 
records  and  reports  and  the  amount  spent  in  traveling  about 


25 8     SCHOOL  HEALTH  ADMINISTRATION 

from  school  to  school,  could  not  well  be  determined.  Even 
the  number  of  days  annually  in  which  doctors  made  school 
visits  could  not  in  all  cases  be  learned.  The  work  varies  for 
physicians  from  an  average  of  a  very  few  hours  a  year, 
probably  less  than  fifty,  up  to  two  hours  a  day  for  each 
school  day  in  the  year  (say  350  hours),  and  some  give  three 
hours  daily  though  not  so  regularly,  while  the  nurses'  hours 
are  very  close  to  a  standard  of  a  five-and-a-half  day  week  of 
seven  to  eight  hours  daily. 

C.  The  variability  is  great  in  the  forms  of  administra- 
tion and  execution  of  the  work.    Some  cities,  like  Brockton 
and  Norwood,  almost  eliminate  the  physician,  while  others, 
like  Newark,  put  the  emphasis  upon  the  physicians,  although 
the  tendency  is  strongly  toward  placing  the  work  more  and 
more  in  the  hands  of  well  trained  school  nurses.    Some  cities 
have  the  work  in  the  charge  of  the  boards  of  health,  others 
in  charge  of  boards  of  education,  while  others  divide  the 
work  between  the  two  departments.    We  have  studied  cities 
that  have  no  doctors  and  others  that  have  no  nurses  for 
comparison.     Some  cities  have  only  inspection  systems  of  a 
limited  kind  (for  infectious  diseases)  while  others  have  sys- 
tems much  broader  than   inspection   and  including   annual 
physical   examinations,    cumulative   record   cards,    adequate 
reporting,  and  great  emphasis  upon  curative  and  preventive 
measures.     All-round  school  clinics  are  only  being  agitated 
as  yet. 

D.  The    variability   might    also    be    illustrated   by    the 
tables  of  ailments  and  the  very  different  proportions  for  any 
one  ailment  from  zero  to  sixty  or  more  per  hundred  chil- 
dren. 

II.  The  cost  of  medical  inspection  also  varies  greatly  as 
shown  for  salaries.  The  average  salary  for  physicians  is 
about  $400  with  great  variations,  while  the  salaries  of 
nurses  is  near  $75  a  month  for  the  school  year,  and  some  for 
the  summer,  one  or  two  months.  Supervisors'  salaries  range 
from  $800  up  to  nearly  $4,000.  Only  one  board  of  health 
has  a  special  supervisor  of  this  work,  and  he  gets  the  lowest 
salary.  A  city  may  be  paying  very  small  salaries  to  its  school 


PHASES  OF  MEDICAL  INSPECTION       259 

physicians  and  yet  be  paying  more  than  a  city  with  a  large 
annual  salary,  when  the  amounts  of  time  spent  during  the 
year  in  actual  school  medical  work  are  compared.  Other 
expenditures  for  medical  inspection  are  as  yet  very  small 
because  of  lack  of  free  clinical  treatment.  The  total  expendi- 
tures and  relative  expenditures  are  given  in  the  tables. 
Adequate  systems,  as  here  recommended,  will  cost  from  one 
to  four  per  cent  of  current  expenditures.  Scientific  reor- 
ganization of  many  existing  systems  of  educational  hygiene 
as  a  whole  need  cost  little  more  than  is  at  present  spent  for 
a  variety  of  uncorrelated  health  provisions. 

III.  Methods    and    technique    of    inspection    are    very 
chaotic,   and  most  reports   of  the  work  are  so   inaccurate 
and  meaningless  as  to  be  practically  worthless.     Little  can 
as  yet  be  said  as  to  what  medical  inspection  is  accomplishing 
for  schools.     Record  systems  need  greatly  to  be  simplified 
so  efficiency  will  be  promoted,  not  discouraged.     Medical 
inspection  must  be  correlated  with  all  other  phases  of  edu- 
cational   hygiene:    medical    inspection,    physical    education, 
school  sanitation,  the  teaching  of  hygiene,  and  the  hygiene 
of  teaching.    The  work  has  and  should  broaden  out  beyond 
"inspection"  to  include  annual  (physical)   examinations  and 
generous  curative  and  preventive  measures.     Medical  Su- 
pervision of  Schools  would  be  a  good  term  to  cover  all 
phases,  but  the  writer  does  not  urge  its  adoption  because  of 
the  difficulty  of  getting  the  name  generally  used.     Health 
Supervision  will  not  do  because  this  describes  the  scope  of 
the  entire  department  of  hygiene,  and  may  be  confused  with 
the  city  health  department.    The  chief  criticism  of  methods 
will  be  found  in  the  last  chapter  in  the  form  of  a  plan  for 
doing  the  work  efficiently  and  well.    We  have  avoided  draw- 
ing deadly  comparisons  and  of  showing  up  as  much  ineffi- 
ciency as  possible.    Most  cities  are  willing  to  make  desirable 
improvements  when  they  see  that  they  are  improvements. 
The  final  chapter  meets  this  need  better  than  any  amount  of 
muck-raking.     The  tables  are  largely  self-explanatory. 

IV.  The   nomenclature  and  the  classification   of  school 
ailments  and  the  various  phases  of  medical  inspection  should 


26o    SCHOOL  HEALTH  ADMINISTRATION 

be  widely  adopted  for  promoting  reasonable  uniformity  and 
greater  efficiency.  The  plan  of  placing  the  curative  work 
of  the  nurse  in  juxtaposition  with  the  cases  found  by  nurse 
or  physician  should  be  adopted.  Some  of  the  essentials  for 
each  ailment  are  as  follows : 

1.  Number  of  new  cases  (serious,  not  minor)  found  and 
referred  for  treatment  by  (a)  the  doctor,  and  by  (b)   the 
nurse. 

2.  Number  of  old  cases  inspected  by   (a)    the  doctor, 
and  (b)  the  nurse. 

3.  Number  of  these  cases  which  were  found  negative  by 
family  physicians  and  agreed  as  such  by  the  school  physician 
or  nurse. 

4.  After  subtracting  the  negative  cases  (where  the  diag- 
nosis has  been  determined  wrong  or  the  child  not  needing 
treatment),  the  total  number  of  new  and  old  remaining,  yet 
to  be  followed  up  until  treated  and  cured. 

5.  The  number  of  cases  (ailments,  perhaps  several  for 
some  children)    (a)   treated  by  the  nurses  of  school  clinic, 
(b)  treated  by  other  agencies,   (c)  cured. 

6.  Number   of  children   excluded   for  the  various   ail- 
ments, counting  only  one  ailment  as  causing  exclusion,  num- 
ber re-excluded  after  presenting  themselves  at  the  school, 
and    (c)    the   number   re-admitted  after   illness,    exclusion, 
quarantine,  absence  of  three  days  or  more,  and  the  number 
admitted  for  the  first  time,   after  the  first  two  weeks  of 
school,  i.e.,  after  the  routine  September  room-inspection  of 
all  school  children. 

7.  The  number  of  remaining  cases   (ailments)   not  yet 
(a)  treated,  (b)  cured. 

The  classified  list  of  ailments  later  recommended  as  a 
beginning  standard  should  be  placed  at  the  left  of  the  page 
for  the  report,  weekly,  monthly  or  annually,  with  the  above 
rubrics  as  headings.  Other  significant  data  are  given  on  the 
alternative  recommended  weekly  report  of  the  nurse  for 
the  work  of  the  doctor  and  herself.  This  type  of  report, 
when  well  used  will  balance. 


PHASES  OF  MEDICAL  INSPECTION        261 

V.  Few  of  the  cities  yet  have  annual  medical  examina- 
tion of  all  elementary  pupils;  and  Boston  and  South  Man- 
chester, Conn.,  were  the  only  ones  that  had  done  much  in 
the  high  school  field.  Medical  examination  and  even  inspec- 
tion reaches  but  a  small  proportion  of  the  total  number  of 
children  in  the  schools,  and,  although  many  cures  are  re- 
ported in  certain  cases,  the  results  in  this  direction  are  very 
meager.  Free  school  clinics  are  recommended. 


CHAPTER  TEN 

PHYSICAL    EDUCATION    AND    OTHER    PHASES    OF 
EDUCATIONAL    HYGIENE 

Following  a  simple  working  classification  of  the  various 
divisions  of  educational  hygiene,  we  have  now  completed  but 
one  phase  or  department,  that  of  medical  inspection.  The 
short  section  on  Conclusions  on  Medical  Inspection  has  at- 
tempted to  bring  together  in  succinct  form  the  chief  results 
and  principles  arising  from  our  study  of  the  health  pro- 
visions in  the  twenty-five  cities  chosen  for  this  investigation. 
There  remain  yet  for  consideration  and  study  the  following 
divisions :  Physical  Education,  School  Sanitation,  The 
Teaching  of  Hygiene,  and  the  Hygiene  of  Teaching.  In 
this  chapter  we  can  give  but  briefly  the  main  data  and  con- 
clusions arrived  at  in  the  study  of  these  phases  in  these 
cities. 

In  an  investigation  of  school  health  provisions,  medical 
inspection  naturally  comes  first,  since  it,  more  than  anything 
else,  points  out  those  pathological  weaknesses  of  our  chil- 
dren which  it  is  the  main  business  of  most  of  the  other 
divisions  to  prevent  and  correct.  If  the  work  of  doctors 
and  nurses  shows  that  a  large  percentage  of  the  children 
are  poor  in  health  and  bodily  efficiency,  that  they  are  living 
unhygienically  at  home  and  at  school,  and  that  they  suffer 
from  a  whole  host  of  preventable  ailments,  then  we  have 
clearly  laid  before  the  whole  school  system  and  all  the 
homes  their  problem  and  duty  relative  to  health.  Medical 
inspection  can  do  much  in  the  finding  of  ailments  and  in  their 
cure.  It  can  by  no  means  cover  all  the  fields  of  prevention 
in  the  form  of: 

i.  Improving    the     school     environment,     hygienically, 
through  school  sanitation; 

262 


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264     SCHOOL  HEALTH  ADMINISTRATION 

2.  Promoting  normal  physical  development,  vital  resist- 
ance,   and   certain   indispensable   health  habits   and   ideals, 
through  physical  education; 

3.  Giving  adequate  health  education,   including  knowl- 
edge, habits,  ideals,  and  appreciations,  to  the  children  of  the 
schools  and  through  them  to  the  homes. 

4.  Managing   and   teaching   the   children   in   the   most 
hygienic  manner,  making  the  methods  of  teaching  and  the 
life  of  the  school  such  as  will  promote  health  and  happiness, 
prevent  rather  than  cause  physical  defects,   and  given  the 
nation  what  Dr.  Burnham  calls  a  "militia  of  health"  instead 
of  inefficient  and  unreliable  candidates  for  the  sanitarium.* 

A.  PHYSICAL  EDUCATION 

A  tremendous  development  of  physical  education  has  re- 
cently taken  place  in  the  form  of  the  playground  movement 
and  all  that  it  implies,  and  in  the  beneficent  reaction  upon 
the  old,  stilted,  fatiguing,  isolated,  and  unnatural  formal 
gymnastics  inherited  from  military  and  autocratic  sources. 
We  have  shown  in  a  former  chapter  the  tremendous  devel- 
opment of  this  new  form  of  life  and  activity  for  children. 
Like  all  of  the  other  new  health  agencies  which  have  re- 
cently been  crowded  into  the  public  schools  largely  by  lay 
bodies  from  without,  we  have  here  another  illustration  of 
a  lack  of  integration  with  all  other  health  agencies  of  the 
schools,  of  adequate  scientific  leadership  and  control,  and  of 
proper  scientific  management  and  economy.  Like  many 
other  health  provisions,  too,  the  play  movement  is  still  quite 
largely  in  the  private  and  voluntary  stage  of  development. 

The  principal  phases  of  this  form  of  physical  education 
found  by  the  writer  were : 

i.  Increased  playground  space,  not  only  by  and  near 
the  schools,  but  in  parks,  vacant  lots  and  other  places,  and 
provided  by  playground  commissions,  park  commissions 
and  many  private  agencies.  The  natural  play  center  is, 

*See  "The  Problems  of  Child  Hygiene,"  by  W.  H.  Burnham,  in  the 
1912  volume  of  the  proceedings  of  the  N.  E.  A. 


DIVISIONS  OF  HYGIENE  265 

of  course,  at  the  school,  also  the  best  place  for  community 
parks. 

2.  Increased  school-  and  factory-made  play  apparatus  in 
school  yards. 

3.  Folk   dancing   in   charge   of   special    instructors   em- 
ployed for  this  work  alone  at  the  schools. 

4.  School  athletic  leagues  in  increasing  numbers. 

5.  Emphasis  upon  more  democratic  and  better  directed 
athletics  in  the  high  schools. 

6.  After  school  and  Saturday  direction  of  play  and  ath- 
letics of  elementary  children  by  school  masters. 

7.  Increased  number  of  gymnasiums  in  the  new  and  old 
school  buildings. 

8.  Increased  number  of  physical  training  teachers  and 
supervisors. 

9.  Increased  number  of  evening  recreation  centers. 

10.  Emphasis    on    the   provision    of   skating  rinks    for 
school  children  in  winter. 

11.  Increased  attention  to  the  educational  value  of  play 
and  to  its  correlation  with  other  motor  activities  such  as 
industrial  work,  especially  in  vacation  schools. 

12.  Increased  attention  to  the  direction  of  the  recess 
and  other  free  play  periods  of  school  children. 

13.  Increased  number  of  summer  playgrounds  and  play- 
ground instructors  and  directors. 

14.  Emphasis  upon  swimming  and  bathing  for  school 
children,  especially  in  the  summer. 

15.  Growing  use  of  play  festivals,  pageants,  and  the 
like. 

It  might  have  been  well  for  us  to  have  carried  through 
rigorously  the  exact  amount  of  work  in  all  health  fields  that 
each  city  gave  during  the  years  studied.  Comparisons,  how- 
ever, may  be  helpful  and  they  may  be  odious,  according  to 
an  old  saying.  We  shall  be  content  if  we  have  sketched  a 
method  of  analyzing  the  health  work  of  a  city,  and  shown 
even  vaguely  how  efficiency  tests  may  be  applied  to  them. 
We  studied  in  some  detail  the  cost,  equipment,  workers, 
methods,  and  results  as  well  as  they  could  be  learned  of  all 


266     SCHOOL  HEALTH  ADMINISTRATION 

play  agencies,  public  and  private,  in  the  cities  chosen.  But 
we  cannot  give  here  all  the  details  necessary  for  discriminat- 
ing and  comparative  work.  We  do  give  in  the  following 
table  the  main  public  school  physical  education  expenditures, 
including,  of  course,  playgrounds  summer  and  winter. 

Any  examination  of  this  table  will  show  that  a  consid- 
erable number  of  cities  are  doing  little  or  nothing  in  a  spe- 
cial way  for  the  physical  development  of  the  school  children, 
and  that  it  is  only  in  the  largest  city,  Boston,  that  we  find 
any  extended  development  of  physical  development  agencies 
that  seem  at  all  adequate  either  in  the  old  Greek  or  modern 
sense.  Many  cities  had  no  physical  training  teachers,  play- 
ground instructors,  or  even  ten-  or  fifteen-minute  periods 
during  the  school  days  for  school  room  calisthenics  or  games. 
In  some  schools  and  cities  there  has  even  been  a  tendency 
toward  cutting  out  the  good,  old-fashioned  recess,  of  so 
much  value  in  a  physical  way  to  the  children.  It  is  difficult 
to  state  a  number  of  these  facts  by  cities,  for  occasional 
schools  may  be  held  up  as  exceptions  in  almost  any  city,  and 
any  general  statement,  unless  favorable,  may  be  resented. 

On  the  other  hand,  the  general  tendency  is  strongly  in 
the  direction  of  increased  health  provisions,  and  a  study  of 
the  reports  of  these  school  systems  for  the  four  years  from 
1909  to  1912,  inclusive,  has  shown  some  almost  radical 
transformations  in  this  direction.  Such  statements  as  the 
following  are  significant,  in  the  first  report  (1910)  of  Dr. 
Hermann,  then  Director  of  Physical  Education  at  Cam- 
bridge: "We  have  instituted  both  a  morning  and  an  after- 
noon recess  (italics  mine),  which  are  taken  out  of  doors 
whenever  the  weather  and  the  yard  conditions  are  favor- 
able. Without  this,  only  the  most  active  children  would  get 
sufficient  exercise,  and  the  teachers  would  not  have  the 
opportunity  to  study  their  charges  while  at  play." 

Particularly  marked  development  along  these  lines  has 
taken  place  in  New  Bedford,  Trenton,  Cambridge,  Newark 
and  Boston. 

Beginning  again  with  the  whole  department  of  physical 
education,  not  including  play  and  playgrounds,  we  found 


DIVISIONS  OF  HYGIENE  267 

the  following  phases,  in  one  or  more  of  the  cities,  to  analyze 
out  and  study : 

1.  General    Director    of    Department    of    Hygiene,    at 
Boston  only    (lacking  here  only  the  school  physicians,   to 
make  the  department  complete). 

2.  Assistant   directors    of   physical   education,    three    at 
Boston  and  two  at  Newark. 

3.  Supervisors  of  physical  training  or  of  physical  edu- 
cation, largely  the  former,  having  only  restricted  duties,  not 
having  general  oversight. 

4.  Elementary    school    teachers    of    physical    training, 
play,  folk  dancing,  and  all  that  the  subject  now  includes, 
number  and  salaries. 

5.  High  school  teachers,  or  "directors"  of  gymnasiums, 
gymnastics,   athletics,   physical   examinations,   and  the   like, 
number  and  salaries. 

6.  Clerical  assistants  for  several  of  these  departments, 
number  and  salaries. 

7.  Military    drill    masters,     assistants,     and    armorers, 
number  and  salaries  and  the  work  of  the  cadets. 

8.  Number  of  school  gymnasiums,  elementary  and  high 
schools,  including  separate  drill  halls,  and  the  like. 

9.  Cost  of  equipment  and  maintenance  for  these. 

10.  Number  of  gymnasiums  used  for  evening  recreation 
work. 

11.  Number  of  swimming  pools,  shower,  and  tub  baths 
in  elementary  and  high  schools. 

12.  Number  a^d  salaries  of  bath  matrons,  and  special 
janitors  for  baths. 

13.  Number  of  outside  public  or  private  baths  open  to 
school  children. 

14.  Two-minute   or    ten-    or   fifteen-minute    recreation, 
play,   or  calisthenic  exercise   in  the  class-room  by  regular 
teachers. 

15.  Salaries  of  special  repair  men  for  gymnasiums. 

1 6.  School    athletic    leagues,    their    hand-books,   their 
membership  and  expenditures,  private  and  public. 


268     SCHOOL  HEALTH  ADMINISTRATION 

17.  Special  coaches  in  athletics  in  high  or  elementary 
schools. 

1 8.  Substitutes  in  physical  education  and  their  manage- 
ment and  salaries. 

19.  Number  of  lectures  to  pupils  on  physical  develop- 
ment and  general  health  topics. 

20.  Employment  of  sub-masters  for  directing  play  after 
school  and  Saturdays,  Boston. 

21.  Efforts  in  the  field  of  medical  gymnastics. 

Tables  when  made  on  the  basis  of  most  or  all  of  such 
divisions,  as  proved  the  case  for  all  other  phases  of  educa- 
tional hygiene,  and  even  for  the  compact  table  of  school 
ailments  made  for  medical  inspection — isuch  tables  were 
pretty  much  blank  spaces,  not  only  because  of  the  hetero- 
geneity of  the  work  as  yet,  but  also  for  the  reason  that 
many  school  systems  have  not  yet  engaged  themselves  seri- 
ously with  the  problem  of  physical  education.  We  are  still 
very  far  from  the  Greek  ideals  of  harmonious  bodily  effi- 
ciency. A  revolution  must  gradually  be  worked  in  the  idea 
of  public  education  itself  before  schools,  school  curricula, 
and  school  administration  are  adjusted  to  the  health  and 
bodily  needs  of  the  children  of  urban  civilization.  This  will 
be  pointed  out  more  particularly  under  the  hygiene  of  teach- 
ing. Much  of  the  promise  in  the  cities  here  studied  lies  in 
the  construction  of  new  school  buildings,  planned,  not  for 
disembodied  mentalities,  nor  for  rural  children  getting 
fairly  adequate  physical  and  motor  development  in  the  out- 
of-school  life,  but  for  the  cooped-up,  sedentary,  in-door, 
flat-dwelling  children,  limited  within  by  the  restrictions  of 
apartment-house  and  school  life,  and  without  by  the  dangers 
and  policemen  of  the  streets.  That  such  a  life  as  is  rapidly 
developing  in  this  country  will  speedily  kill  off,  through  the 
law  of  survival,  all  those  unadapted  to  it  and  leave  a  people 
healthily  adjusted  to  such  conditions,  may  only  partially  be 
looked  to,  for  the  simple  fact  of  the  lower  birth-rate  in  cities 
and  the  need  of  constant  replenishment  by  Country  folk. 
Beside  this  force  and  possible  eugenic  control  there  must  be 
rigorous  and  radical  transforming  of  the  environment  and 


DIVISIONS  OF  HYGIENE  269 

education  of  the  rising  generations,  especially  at  the  schools. 
Adequate  health  education  may  be  expected  to  react  upon 
the  health  conditions  of  home  and  business  life,  making  them 
in  turn'  more  hygienic  and  healthful.* 

PHYSICAL  EDUCATION  SUPERVISORS 

Thirteen  of  the  twenty-five  cities  could  be  said  to  have 
had  at  this  time  supervisors  or  directors  of  physical  training, 
but  in  only  three  or  four  could  these  officials  be  regarded, 
perhaps,  as  directors  of  physical  education.  A  person  who 
merely  teaches  physical  training  in  elementary  or  high 
schools,  and  who  has  no  general  responsibility  for  or  super- 
vision of  all  forms  of  physical  education  such  as  mentioned 
above  could  hardly  be  called  a  director  or  supervisor  of 
physical  education.  We  should  probably  put  Cambridge, 
Newark  and  Boston  in  this  class,  and  perhaps  others.  We 
have  listed  as  supervisors,  however,  ten  others  with  more 
limited  responsibilities.  A  person  may  well  be  supervisor 
of  physical  training  or  of  physical  education  in  the  ele- 
mentary schools  or  in  the  high  schools  alone,  but  such  divi- 
sion leaves  an  uncorrelated  system.* 

The  salaries  at  South  Manchester  and  Winchester  are 
for  part-time  services.  The  salaries  really  range  from 
about  $1,000  to  about  $4,000,  the  director  of  hygiene  at 
Boston  receiving  at  that  time  $3,800,  and  the  assistants 
about  $2,400  each.  At  Yonkers,  no  one  physical  training 
teacher  seemed  to  be  supervisor  and  no  report  on  physical 


*I  do  not  wish  to  suggest  here  that  country  children  are  not  in 
need  of  radically  improved  hygienic  conditions.  In  making  this  study 
the  writer  traveled  over  a  large  portion  of  New  England,  New  York 
and  New  Jersey  in  street  cars,  thus  coming  close  once  more  with  coun- 
try folk;  and  the  most  vivid  impression  of  the  people  met  was  that  of 
their  low  physical  efficiency.  Of  course  urban  and  western  selection 
has  taken  off  most  of  the  vigorous,  physically  superior  individuals,  as 
the  wars  of  Europe  have  cut  off  its  stronger  and  abler  types,  but  after 
subtracting  this  influence  we  must  admit  the  possibility  of  raising  con- 
siderably the  hygienic  conditions  of  country  life.  See  also  Gillette's 
"Constructive  Rural  Sociology." 

*See  the  excellent  chapters  in  Johnston's  High  School  Education 
(Scribner's)  on  "Physiology  and  Hygiene,"  and  "Sex  Pedagogy  in  the 
High  School"  and  other  chapters  in  Vol.  II. 


270     SCHOOL  HEALTH  ADMINISTRATION 

education  appears  in  the  1910-11  annual  report.  Seven 
cities,  apparently,  had  no  special  teachers  in  this  field.  In 
Rochester  the  supervisor  is  employed  for  the  work  of 
directing  the  summer  playgrounds,  and  this  is  also  true  of 
Boston.  There,  the  services  of  the  director  are  for  eleven 
months.  In  Boston  and  Newark,  all  officials  in  this  field 
of  work  are  on  a  salary  schedule,  with  minimum  and  maxi- 
mum salaries.  This  is  highly  desirable,  as  is  also,  for  the 
most  part,  the  twelve  payments  a  year  plan. 

ELEMENTARY  SCHOOL  TEACHERS  OF  PHYSICAL  TRAINING 

After  subtracting  the  supervisors,  so-called,  we  have 
but  few  special  teachers  of  this  subject  left  for  the  element- 
ary schools.  It  is  also  a  problem  whether  many  or  most 
of  these  cities  need  many  such  teachers.  In  another  chapter 
the  author  has  evolved  a  plan  by  which  a  physician  with 
knowledge  and  experience  in  physical  education  may  be 
employed  by  a  city  or  several  small  cities  or  a  country 
township  or  county,  and  given  the  directorship  of  all  five 
phases  of  educational  hygiene,  thus  making  possible  the 
elimination  of  much  of  the  present  expenditures  for  poorly 
trained  medical  examiners  and  physical  training  supervisors. 
The  present  physical  directors  in  the  high  school  gymnasi- 
ums should  be  retained,  and,  if  need  be,  one  or  more  phy- 
sical training  teachers  for  the  elementary  schools.  If  com- 
petent nurses  are  employed  for  about  each  1500  to  2000 
school  children  they  may  be  given  also  the  present  work 
of  the  attendance  officers;  no  general  directors  of  summer 
playgrounds  need  be  employed,  except  in  cities  large  enough 
to  have  assistant  directors;  fewer  part-time  physicians  need 
be  employed,  as  suggested;  and  in  all,  for  a  great  many 
cities,  a  re-organized  and  efficient  system,  correlating  all 
health  agencies,  may  be  obtained,  even  when  paying  the 
general  physician-director  $3,000  or  more,  for  little  more 
annual  expense  than  under  the  present  poorly  directed  and 
un-organized  plans  of  management.  The  writer  knows  of 
twenty-five  available  and  qualified  men  for  such  positions 
now.  More  young  physicians  will  take  the  training  neces- 


DIVISIONS  OF  HYGIENE  271 

sary  when  a  demand  is  evidenced.  We  probably  need 
more  Doctors  of  Public  Health  (D.  P.  H.)  rather  than 
so  many  Doctors  of  Philosophy  (Ph.D.).  The  possible 
saved  expenditures  in  this  direction  for  these  cities  should 
be  subtracted  from  the  estimates  of  needed  hygiene  officials 
given  in  table  XII. 

Besides  the  ten  or  more  physical  training  teachers  for 
the  elementary  schools,  Boston  had  a  most  interesting  ex- 
periment in  the  employment  of  60  male  teachers  of  the 
schools  (sub-masters)  to  go  out  with  the  boys  to  the  parks 
and  playgrounds  after  school  and  Saturday  mornings  to 
direct  them  in  their  sports.  Each  teacher  is  paid  $1.25 
extra  for  each  period,  six  a  week,  and  the  whole  scheme 
has  seemed  to  be  eminently  successful. 

Instead  of  giving  the  amounts  expended  for  such  teach- 
ers and  high  school  directors  in  the  two  largest  cities, 
we  give  only  the  minimum  and  maximum  salaries,  the 
teachers  being  at  different  points  in  the  schedules  as  was 
the  case  of  the  35,  and  now  41  or  more,  nurses  in  Boston, 
and  the  eight  in  Newark.  Wherever  two  or  more  teachers 
or  directors  are  recorded  their  combined,  and  not  their 
separate,  salaries  are  given.  Thus  the  two  assistant  super- 
visors at  Newark  received  $1,100  and  $1,400  respectively, 
or  $2,500  together  (maximum,  $2,000)  ;  and  the  three 
teachers  at  Rochester  received  a  combined  sum  of  $3,300. 
This  would  also  apply  to  Yonkers,  and  also  to  the  play- 
ground teachers  in  several  places. 

Like  the  school  nurses,  the  physical  training  teachers 
are  practically  all  graduates  of  special  schools  or  depart- 
ments for  such  work.  We  found  only  one  nurse  who 
had  only  the  qualifications  of  a  regular  grade  teacher  (at 
Lowell)  and  we  found  only  one  teacher  of  physical  train- 
ing who  had  "just  picked  it  up."  It  is  easy  today  to  get 
superior  training  in  this  field,  but  not  in  the  field  of  medical 
inspection,  and  there  are  still  no  schools  for  the  education 
of  directors  of  hygiene  which  will  abridge  the  medical 
course,  leaving  out  much  in  such  special  fields  as  obstetrics 
and  adult  treatment  as  will  not  function  and  putting  in 


272     SCHOOL  HEALTH  ADMINISTRATION 

much  left  out  by  the  regular  medical  course.  We  are  not 
aware  that  the  University  of  Wisconsin  has  provided  prepa- 
ration for  this  service  in  its  new  health  department.  Teachers 
and  directors  can  now  obtain  a  good  library  and  can  get 
a  good  summer  course  on  the  medical  aspects  of  their  work. 

HIGH    SCHOOL   TEACHERS    OF    PHYSICAL    TRAINING 

Eleven  or  more  of  the  twenty-five  cities  had  one  or 
more  teachers  of  physical  training  in  the  high  schools.* 
Most  of  the  newer  high  schools  were  being  supplied  with 
gymnasiums,  as  well  as  many  of  the  new  elementary  schools, 
and  generally  we  found  at  each  high  school  thus  equipped 
a  man  for  the  boys  and  a  woman  for  the  girls  conducting 
the  department.  In  some  cases,  as  at  Montclair  and 
Lowell,  outside  buildings  have  been  rented  or  purchased 
for  such  provisions.  The  $500  salary  at  Lowell  was  for 
the  part-time  services  of  a  drill  master  for  the  boy  cadets. 
In  this  city,  Boston,  Brockton,  and  a  few  other  cities,  more 
or  less  attention  is  being  paid  to  this  form  of  health  de- 
velopment, largely  for  high  school  students.  It  is  much 
more  military  in  character  than  the  Boy  Scouts  scheme, 
and  probably  not  so  valuable.  The  cadets  in  Brockton, 
however,  take  trips  somewhat  as  do  the  Boy  Scouts.  Both 
have  uniforms,  but  with  a  difference.  Of  one  of  these  suc- 
cessful cadet  organizations  Professor  Wm.  H.  Burnham, 
the  dean  of  educational  hygienists  in  this  country,  has  this 
to  say: 

"A  few  weeks  ago  it  was  my  privilege  to  witness  the 
parade  of  the  high  school  cadets  of  Boston,  a  parade  of 
two  or  three  thousand  school  boys.  It  was  an  excellent 
exhibition  of  the  results  of  careful  drill  and  organization. 
The  cadets  did  credit  to  themselves  and  to  their  military 
instructors.  But  as  I  observed  them  as  they  marched,  I 
noticed  how  many  were  sallow  in  countenance,  anemic,  or 
flat  chested,  or  mouth  breathers,  or  apparently  suffering 


*See  Gulick's  study  of  the  "Status  of  Physical  Education  in  90 
Public  Normal  Schools  and  2,392  Public  High  Schools  in  the  United 
States."  Fourth  National  School  Hygiene  Congress. 


DIVISIONS  OF  HYGIENE  273 

from  some  physical  disorder  or  defect  or  bad  condition; 
and  how  few  had  the  ruddy  glow  and  the  general  aspect 
of  health  that  the  adolescent  should  exhibit.  These  were, 
however,  in  a  certain  sense,  the  pick  of  the  pupils  in  the 
public  schools. 

"If  this  is  the  price  that  must  be  paid  for  education, 
it  is  no  wonder  that  parents  are  dissatisfied  and  that  they 
ask  whether  the  reward  is  worth  the  sacrifice.  What  man 
of  sense  would  bargain  vigorous  health,  normal  develop- 
ment, and  a  few  motor  accomplishments  like  those  of  the 
Boy  Scouts  for  a  little  conventional  book-knowledge  and 
anemia  and  ill-health  and  mal-development?" 

He  furthermore  recommends*  that  drill  in  health  habits 
be  substituted  in  part  for  the  special  drill  in  military  tactics, 
and  the  development,  not  of  a  kind  of  police  force,  but  of 
"a  militia  of  health  trained  to  fight  the  conditions  of  disease 
by  the  methods  of  modern  science" 

This  is  but  one  step  in  the  complete  socialization  of 
the  whole  physical  education  department.  With  scientific 
and  medically  trained  people  in  charge,  we  may  expect 
studies  to  be  made  of  the  health  needs  and  health  problems 
of  the  students  and  the  people  of  the  community  in  order 
to  make  education  hit  the  mark.  What  physical  education 
seems  to  need  is  a  great  deal  more  of  scientific  and  socialized 
intelligence,  rather  than  special  motor  accomplishments. 

We  made  little  or  no  study  of  athletics  and  athletic 
coaches.  The  football,  basketball,  track  meets,  and  all 
the  various  forms  of  outdoor  and  indoor  competitions  fur- 
nish specially  acute  problems  which  take  special  investiga- 
tion and  time  in  each  city.  Most  of  the  progressive  de- 
partments are  now  working  for  or  have  attained,  athletic 
fields,  stadiums,  and  all  the  paraphernalia  of  the  college. 
With  proper  re-organization  of  the  high  school  curricula, 
throwing  out  the  immense  quantities  of  deadwood  that  have 
accumulated  for  ages  of  formal  discipline  theories,  and  with 
the  introduction  of  thoroughly  essential  educational  activi- 


*See  1912  volume  of  the  N.  E.  A.,  page  1102. 


274     SCHOOL  HEALTH  ADMINISTRATION 

ties,  we  may  expect  these  health  fields  and  equipment  to 
provide  thoroughly  democratic  and  general  physical  and 
social  development  of  the  old  Greek  type  and  better. 

MEDICAL    EXAMINATIONS    AND    EMERGENCY    TREATMENT 

In  all  first-class  high  school  departments  of  this  kind,  as 
in  normal  schools  and  colleges,  physical  examinations  and 
emergency  diagnosis  and  treatment  are  attempted.  The  sad 
fact,  however,  is  that  most  high  school  gymnastic  directors 
are  not  properly  qualified  for  such  work.  In  asking  them 
for  their  views  on  medical  inspection,  they  nearly  always 
request  that  the  physicians  make  their  heart  and  lung  ex- 
aminations for  those  going  into  athletics  because  they  "do 
not  feel  properly  qualified";  they  do  not  have  a  medically 
trained  eye  always  to  notice  fairly  obvious  indexes  of  phy- 
sical defects  and  other  ailments;  and  so,  instead  of  being 
the  health  guardians  of  the  high  school,  able  to  discover  all 
health  impediments  to  education  and  to  act  as  general 
medical  and  sanitary  inspectors  of  the  school,  we  have  them 
occupying  a  little  isolated  niche.  Such  a  lack  of  medical 
qualifications,  is,  of  course,  very  expensive  to  the  school 
system  that  tries  to  do  the  best  for  the  hygiene  of  the 
school.  The  male  physician-director  of  the  normal  school 
can  adequately  examine  his  pupils,  with  their  clothing  re- 
moved, for  heart,  lung  and  other  examinations,  and  the 
woman  physician  director  can  also  adequately  examine  and 
inspect,  when  necessary,  her  pupils.  Trouble  arises  when 
this  is  attempted  by  outside  or  part-time  physicians,  and  the 
only  economical  method  in  the  long  run  will  be  for  these 
two  or  more  teachers  who  meet  all  the  pupils  perhaps 
every  week,  to  be  physicians,  or  have  special  medical  knowl- 
edge, and  do  the  work  of  medical  examination  and  inspec- 
tion. Many  illustrations  from  life  could  be  given  of  the 
even  fatal  results  coming  from  having  under-educated  health- 
development  teachers  in  charge  of  this  vitally  essential  work. 

Boston  gets  around  this  difficulty  partly  by  having 
qualified  persons  in  the  high  schools,  partly  by  having  special 
physicians  employed  for  medical  examinations  in  the  high 


DIVISIONS  OF  HYGIENE  275 

schools,  and  partly  by  having  a  director  of  hygiene  who 
is  also  a  physician.  The  last  is  a  part  of  the  essentials 
of  the  plan  proposed  by  the  writer  in  the  next  chapter. 
Let  us  not  forget  that  under  the  proper  kind  of  a  director 
of  hygiene  these  high  school  directors  may  be  taught  to 
do  this  work  satisfactorily  in  many  cases.  We  have  in- 
stances where  regular  teachers,  working  with  school  phy- 
sicians, have  acquired  rare  powers  in  this  direction. 

GYMNASIUM    AND    GYMNASIUM    BATHS 

At  least  sixteen  or  seventeen  of  the  cities  had  baths  in 
one  or  more  of  the  schools,  elementary  and  high,  but  mostly 
the  latter,  and  both  tubs  and  showers,  but  mostly  the  latter. 
South  Manchester  each  year  gives  a  good  report  of  the 
school  baths,  and  we  find  that  at  one  school  during  1910-11 
as  many  as  12,858  baths  were  taken.  In  all  modern  schools 
where  there  are  gymnasiums  or  where  there  are  equipped 
playgrounds  adjacent,  we  found  one  or  more  shower  baths 
for  both  boys  and  girls.*  We  found  that  about  the  same 
number  of  cities  had  gymnasiums  as  had  baths,  although 
they  are  not  co-incident.  These  are  relatively  modern 
additions  to  schools  and  school  boards  have  not  yet  been 
made  to  realize  the  truth  for  school  children,  many  with- 
out bath  tubs  or  parents  with  bath  ideals  at  home,  that 
"cleanliness  is  next  to  Godliness." 

In  a  growing  number  of  cities,  through  the  use  of  bath 
rooms  in  schools  for  summer  playgrounds  and  for  evening 
recreation  centers,  there  is  a  tendency  for  public  school 
baths  to  become  general  public  baths,  and  there  is  little 
reason  why  this  should  not  become  universal,  just  as  much 
as  the  tendency  for  the  school  to  have  within  it  a  branch 
of  the  public  library  or  any  other  of  the  many  agencies 
which  are  being  developed  in  response  to  the  peoples'  needs. 
Too  often  our  schools  are  looked  upon  as  absolute,  un- 


*For  those  interested  in  the  various  types  of  equipment  for  these 
health  features  the  reader  is  referred  to  the  excellent  reports  and  adver- 
tisements in  the  School  Board  Journal,  published  at  Milwaukee. 


276     SCHOOL  HEALTH  ADMINISTRATION 

changing  and  unchangeable  institutions,  instead  of  institu- 
tions purchased  by  the  hard  toil  of  the  many,  and  sup- 
plementary institutions,  now  idle  much  of  the  time,  for  meet- 
ing the  peoples'  needs  and  perplexing  life  problems.  We 
need  scientific  sociologists  who  can  discover  the  needs,  and 
we  must  have  teachers  and  leaders  who  can  best  help  the 
people  to  meet  them  through  this  single  public  neighbor- 
hood institution. 

The  many  other  phases  of  physical  training  we  shall 
not  here  discuss.  They  are  sufficient  in  all  for  a  much 
needed  book.  A  recent  valuable  one  along  this  line  but 
more  for  adults  is  "Exercise  in  Education  and  Medicine," 
by  Professor  R.  Tait  McKenzie,  of  the  University  of 
Pennsylvania.  We  should  have  liked  to  take  space  for  dis- 
cussing the  work  of  medical  gymnastics  along  the  line  of 
mouth  breathing  exercises,  special  exercises  for  spinal  cur- 
vature cases,  and  the  like.  Let  us  turn  our  attention,  how- 
ever, briefly  to  the  before-mentioned  work  of: 

PLAYGROUNDS  AND  PLAYGROUND  TEACHERS 

The  following  interesting  and  relatively  statistical 
phases  of  this  new  movement  were  given  as  much  study 
as  possibilities  of  time  and  available  data  permitted: 

1.  Number  of  school-yard  playgrounds   fitted  up  with 
play  apparatus    and    the    number    supervised,  summer  or 
winter. 

2.  Number  of  these  playgrounds  fitted  up  or  supervised 
by  outside  agencies. 

3.  Number  of  playgrounds  elsewhere  provided  by  the 
board  of  education. 

4.  Number    of    other    public    supported    playgrounds, 
swimming  pools,  or  beaches. 

5.  Number  of  privately  supported  playgrounds,   other 
than  those  at  the  schools. 

6.  Expenditures   for  salaries    of    playground  directors, 
teachers,  caretakers,   etc.,  by  the  board  of  education. 

7.  Expenditures  for  playground  apparatus  by  the  board 
of  education. 


DIVISIONS  OF  HYGIENE  277 

8.  Expenditures    for    enlarging  old  or  purchasing  new 
playgrounds,  grading,  and  the  like. 

9.  Expenditures  for  playground  supplies  other  than  ap- 
paratus. \ 

10.  Expenditures    for   the   rent   of  playground   sites. 

11.  Expenditures  for  tents,  shelters,  toilet  conveniences, 
baths,  etc. 

12.  Number,   qualifications,   and   salaries   of  playground 
directors  or  supervisors. 

13.  Number  of  assistant  directors,  salaries,   etc. 

14.  Number  of   playground   instructors,   salaries,   etc. 

15.  Number  of  weeks  employed,  and  daily  and  weekly 
time  schedules. 

1 6.  Number  of  instructors  for  each  playground  and  how 
selected. 

17.  The  games,   contests,   sports,    and  problems   of  the 
work.     The  writer  was  once  a  public  playground  instructor 
and  realized  some  of  these  problems  in  advance. 

1 8.  Number  of  regular  class-room  teachers  who  by  any 
inducement,  such  as  the  $1.25   at  Boston,  could  be  gotten 
out  upon  the  playgrounds  with  their  children  to  be  young 
again  and  play.     "Come  let  us  play  with  our  children." 

19.  Total  expenditures  for  public  school  playgrounds. 

20.  The  methods  by  which   the  various  private  bodies 
realized  their  aims  in  getting  playgrounds  started  in  the 
schools. 

These  and  a  number  of  other  problems  were  first  ob- 
tained in  note-book,  and  other  original  data  form,  and  then 
placed  on  a  statistical  table  for  the  twenty-five  cities.  But 
it  was  so  much  a  table  of  gaps,  that  it  could  well  be  used 
for  study  only,  and  not  for  printing.  A  few  of  the  many 
items  necessary  for  adequate  knowledge  and  careful  investi- 
gation appear  in  the  Physical  Education  table. 

New  Bedford  and  Boston  stand  out  in  the  writer's  mind 
and  data  as  being  typically  progressive  along  these  lines, 
though  several  other  cities  such  as  Rochester  and  Newark 
might  also  have  been  named.  The  data  were  so  hard  to  get 
that  in  many  cases  we  have  very  inadequate  facts  or  none 


278     SCHOOL  HEALTH  ADMINISTRATION 

to  present.  In  other  cases  we  have  been  able  to  get  all  the 
data  we  desired.  This  seemed  especially  true  of  New  Bed- 
ford, where  a  good  deal  of  scientific  management  seems 
to  pervade  the  school  administration. 

Very  few  cities  outside  of  Boston  have  been  doing  much 
with  the  directed  and  organized  play  during  the  day  ex- 
cept in  summer.  It  is  difficult  to  get  teachers  for  their  own 
or  the  children's  good  to  go  out  and  play  at  any  time, 
without  pay.  In  most  cases  they  need  special  training  for 
such  work.  The  many  children  who  come  to  school,  and 
should  come,  as  early  as  eight  o'clock  in  the  morning  and 
who  stay,  and  should  stay  (because  of  bad  home  or  play 
conditions  elsewhere)  till  four  or  five  in  the  evening,  should 
have  guidance,  protection  and  educative  care.  The  in- 
creased health  efficiency  of  the  teachers  and  the  decrease 
of  teacher-absence  through  illness,  now  so  great  a  source 
of  waste  in  all  cities,  might  easily  be  sufficient  to  warrant 
a  city  for  mere  economy  to  employ,  as  does  Boston,  these 
out-of-school  play  teachers.  Walks,  trips,  excursions, 
"tramps,"  and  the  like,  on  Saturdays,  have  all  been  tried 
by  the  writer  as  a  school  principal  and  were  found  success- 
ful, and  might  easily  be  added  to  the  above  program.  The 
school  system  of  Gary,  Indiana,  is  working  out  much  in 
the  line  of  the  whole  day  and  year  school,  that  many  edu- 
cators have  long  experienced  as  a  real  need  of  childhood. 

A  remarkable  thing  was  the  number  of  privately  sup- 
ported playgrounds.  This  has  recently  been  a  very  popular 
form  of  private  philanthropy,  and  should  be  heartily  en- 
couraged and  guided.  But  the  goal  of  it  all  must  be,  of 
course,  adequately  organized  public  management  of  such 
agencies.  It  is  remarkable  how  much  the  leadership  of 
the  superintendent  of  schools  stands  out  in  all  these  fields 
of  enterprise.  Some  are  excellent,  old-time  scholars,  or 
"hale  fellows  well  met,"  but  they  don't  see  the  need  or 
get  the  results  which  a  modern  community  may  rightfully 
expect. 

The  summer  playgrounds  are  frequently  about  eight 
weeks  in  duration  and  are  often  intimately  united  with  the 
vacation  schools,  as  they  should  be.  The  salaries  range 


DIVISIONS  OF  HYGIENE  279 

from  fifty  to  two  hundred  dollars  a  month.  The  tremend- 
ous development  of  literature  in  this  field  makes  unneces- 
sary detailed  statements  of  costs  or  methods.  The  National 
Playground  Association  of  America  with  its  proceedings, 
and  its  magazine,  the  Playground,  the  books  of  Bancroft, 
Mero,  Johnson,  Perry,  Leland,  Lee,  and  many  others;  the 
pamphlets,  slides,  free  information,  etc.,  of  the  Child  Hy- 
giene Division  of  the  Russell  Sage  Foundation,  and  many 
other  expert  agencies  at  the  command  of  public  school 
systems  desiring  assistance  have  made  unnecessary  here  ex- 
tended treatment.  It  may  be  well  briefly  to  describe  the 
administration  in  the  New  Bedford  public  school  play- 
grounds. 

A  skilled  playground  director  was  brought  from  Toledo, 
Ohio,  and  the  following  force  employed  for  six  weeks  on 
eight  playgrounds  in  the  summer: 

i   supervisor  at  $200. 

8  directors,  one  for  each  playground  (men)..  $600 —  $75  a  term. 

8  first   assistants    (women) 480 —     60  a  term. 

8  second  assistants   (women) 75° —     75  a  term. 

8  men  assistants 800 —  100  a  term. 

8  caretakers,  or  janitors 240 —     30  a  term  extra. 

The  plan  was  to  have  four  persons  on  each  playground. 
There  were  swings,  sand  boxes,  large  combination  ap- 
paratus, teeters,  slides,  merry-go-rounds,  rest  rooms  fitted 
up  with  interesting  books  for  the  children  by  the  public 
library  and  the  schools,  use  of  school  toilets  and  baths, 
trees  and  benches  for  the  parents  and  little  mothers,  and 
first-class  conditions,  generally.  At  night  electric  arc  lights 
illuminated  the  grounds  and  directed  play  was  still  carried 
on,  especially  basketball  and  athletic  games  and  "stunts"  by 
the  older  boys  and  young  working  men.  I  saw  no  evidence 
of  home-made,  or  manual-training-made  apparatus,  which 
I  think  should  be  encouraged  and  which  I  have  found  school 
boys  even  below  the  eighth  grade  quite  able  to  construct 
when  properly  guided,  from  getting  the  materials  from 
the  mills  to  digging  the  holes  and  painting  the  constructions 
bottle-green.  All  the  apparatus  was  very  finely  constructed, 
durable  and  expensive.  It  seems  that  where  there  is  time, 


280     SCHOOL  HEALTH  ADMINISTRATION 

home  blacksmiths  could  make  most  of  the  apparatus  of 
playgrounds  for  which  present  companies  are  charging 
almost  exorbitant  and  seemingly  trust  prices.  The  boys 
should  in  every  case  possible  be  given,  also,  a  chance  to 
show  their  hand. 

Having  reached  our  space  limit  for  the  various  forms 
of  Physical  Education,   let  us  take  a  brief  survey  of  one 
of  the  three  remaining  divisions  of  educational  hygiene  in 
these  cities. 
B.  School  Sanitation. 

Recent  surveys  of  the  hygienic  aspects  of  the  school 
environment  of  our  children  by  the  Linked  States  Govern- 
ment and  other  agencies  have  shown  that  they  are  in  gen- 
eral far  below  the  health  ideals,  knowledge  and  standards 
of  the  present  day.  One  writer  has  declared  that  it  would 
be  a  hygienic  providence  if  half  of  the  vilely  constructed 
and  situated  school-houses  of  this  country  were  to  burn 
down,  in  order  to  make  possible  school  environments  suited 
to  present-day  needs  and  conditions.  The  writer  visited 
one  or  more,  and  as  many  as  ten,  school  buildings  in  each 
city  visited,  excepting  the  fifteen  not  used  for  this  study. 
Some  of  the  new  schools  are  very  close  to  the  best  hygienic 
ideals,  and  their  numbers  are  fortunately  growing.  We 
should  have  state  laws  requiring  the  submission  of  all  plans 
for  school  buildings  to  an  expert,  up-to-date  school  architect 
in  the  state  education  department,  to  help  cities  avoid  the 
employment  of  so-called  architects  who  have  never  planned 
anything  much  more  elaborate  than  a  sawmill,  or  common 
warehouse,  and  these  only  by  copying  imitatively  some  long- 
existing  structure. 

Our  chief  method  was  to  learn  about  some  of  the  more 
administrative  aspects  of  the  school  sanitation  problem. 
Some  of  the  features  investigated  more  or  less  closely 
were: 

1.  The  number,  kind,  cost  and  efficiency  of  the  various 
types  of  sanitary  drinking  fountains  installed. 

2.  The  kinds,  number,  cost  and  efficiency  of  the  vacuum 
cleaning  plants  in  use,  discarded  or  proposed. 


DIVISIONS  OF  HYGIENE  281 

3.  The  number  and  kinds  of  fan  systems  of  ventilation 
in  use,  the  attempts  to  humidify  the  air,  the  use  of  humi- 
diometers  and  regulators  of  temperature  and  moisture. 

4.  The  new  types  of  school  seats  which  make  cleaning 
easy,  and  especially  the  use  of  vacuum  cleaners. 

5.  The  construction,  location  and  arrangement  of  open- 
window  rooms  in  schools. 

6.  The  amounts,  kinds,  efficiency  and  cost  of  the  floor 
oils  used. 

7.  The   amounts,  kinds,   efficiency  and  cost  of  dust-ab- 
sorbing compounds  used  in  sweeping,   as  well  as  the  use 
or  non-use  of  the  feather  dust-raiser. 

8.  Paper  or  cloth  towels,  number,  cost,  kinds,  and  effi- 
ciency. 

9.  Amounts,  kinds  and  use  of  disinfectants  for  schools. 

10.  The  use  of  individual  drinkings  cups,  and  how  cared 
for. 

11.  Experiments  and  investigations  in  the  field  of  school 
sanitation.      "Re^circulation"     has     not    yet    reached    the 
schools. 

12.  The  general  hygienic  character  of  the  buildings  vis- 
ited,   including   fire-proofing,    and   all  the   various   modern 
improvements  for  making  cleanliness  easily  possible. 

13.  General  management  of  the  cleaning  and  janitorial 
service,  and  how  paid,  feudally  or  individually. 

A  large  amount  of  data  was  collected  on  these  phases 
but  the  matter  makes  but  poor  statistical  tables  because  of 
the  aforesaid  lacunae. 

There  was  some  remodeling  of  the  heating,  ventilating, 
toilet,  and  other  sanitary  provisions  in  old  schools  of  a 
number  of  systems,  Syracuse  and  New  Bedford  being  espe- 
cially busy  along  this  line,  it  seemed. 

Sanitary  drinking  fountains  were  found  in  practically 
all  school  systems,  but  in  many,  these  were  only  samples 
sent  in  by  various  companies  in  hopes  of  an  order.  South 
Manchester,  Norwood,  Winchester,  Montclair,  Hoboken, 
New  Bedford,  Cambridge,  and  Boston  had  them  in  almost 
every,  or  in  every  school.  The  Keith  bubbler  seemed  most 


282     SCHOOL  HEALTH  ADMINISTRATION 

used  and  satisfactory,  although  a  host  of  other  types  were 
being  tried  out.  The  writer  saw  fifteen  or  sixteen  that  had 
been  placed  over  the  watering  troughs  of  the  boys'  play- 
room in  one  school  in  Jersey  City.  Only  one  or  two  were 
still  uin  the  ring,"  as  the  boys  said.  One  or  two  had  been 
taken  off  because  of  the  breaking  of  children's  teeth  on 
them  in  the  jostling  crowd.  The  following  requirements  for 
such  fountains  seem  to  stand  out: 

1.  They  must  be  very  strong  and  durable,  not  getting  out 
of  repair,  nor  weak  enough  in  any  part  to  be  screwed  or 
pulled  off  or  apart. 

2.  They  must  provide  cool  water,  not  warm,  in  a  sani- 
tary manner,  with  no  part  touching  the  pupil,  if  possible, 
that  is  not  immediately  washed  off.    A  small  leak,  or  a  plan 
for  turning  the  water  on  and  off  by  the  janitor,  or  the  pos- 
sibility of  running  out  a  large  amount  of  water  quickly  "to 
get  down  to  the  cool"  is  necessary. 

3.  They  must  be  in  batteries  and  over  troughs  to  pro- 
vide  for  many  children,   without  making   a   flood  on   the 
floor. 

4.  They  must  be  safe,  so  no  child  may  be  cut,  get  his 
teeth  broken,  or  anything  of  the  kind  even  when  pushed 
about.      Good  janitor   service   and   training   are   necessary 
here  also. 

5.  They  must  not  be  very  wasteful  of  water,  although 
considerable  loss  is  here  expected. 

6.  They  must  be  placed  on  every  floor,  or  one  in  every 
room,  as  well  as  in  the  basement  play-rooms.     Plenty  of 
pure  water  is  desirable  for  children. 

7.  They  must  be  relatively  inexpensive,  although  certain 
cities  bought  very  costly  porcelain  standards  and  fountains 
at  great  cost. 

8.  It  should  be  made  impossible  for  one  child  to  squirt 
water  over  an  entire  group  or  hall. 

9.  If  placed  out  of  doors  it  must  not  rust  and  it  must 
not  freeze. 

10.  It  should  be  self-closing;  and  the  bubble  or  fountain 


DIVISIONS  OF  HYGIENE  283 

of  water  should  not  rise  at  any  time  more  than  one  and  a 
half  inches.* 

The  prices  range  around  three  to  six  dollars  apiece,  al- 
though the  porcelain  standard  one,  such  as  used  in  Mont- 
clair  in  a  new  school,  costs  about  fifty  dollars  apiece.  New 
Bedford  paid  $1,093  f°r  IX7>  connected  and  in  place,  I 
believe. 

VACUUM    CLEANING    PLANTS 

Very  few  cities  were  using  vacuum  cleaning  plants  in 
the  schools.  South  Manchester  was  the  only  city  using  them 
in  all  schools,  and  the  1909  report  of  the  superintendent 
speaks  very  highly  of  them.  I  saw  the  method  of  using 
them  in  the  high  school  and  agreed  that  they  probably  were 
very  desirable.  The  newer  schools  in  Newark  are  utilizing 
them.  Montclair  has  a  building  piped  for  their  use  but 
has  not  yet  put  in  the  apparatus.  The  piping  can  be  easily 
done  in  new  but  not  in  old  buildings,  so  putting  them  in  is 
wise  foresight,  it  seems.  Waterbury  was  tearing  up  the 
high  school  to  get  pipes  in  when  I  was  there.  Boston  had 
three  such  plants,  two  having  been  installed  in  the  year. 
Rochester  had  put  a  plant  in  several  years  before  (1908) 
in  a  grammar  school,  but  it  had  proved  useless  because  of 
the  faults  of  the  apparatus  perhaps,  but  more  because  the 
head  janitor  was  paid  a  lump  sum,  and  the  women  helpers 
he  employed  could  not  manage  the  apparatus.  "It  was 
more  bother  than  it  was  worth"  to  them.  There  are  easier 
and  dustier  ways.  Careful  investigation  and  experiment, 
careful  selection  of  janitors  on  other  than  the  feudal  sys- 
tem, probably,  careful  training  of  janitors  in  the  use  of 
the  apparatus,  carefully  constructed  floor  (we  need  com- 
position floors  that  are  effective),  and  careful  selection  of 
fewer-legged  desks  and  seats  are  all  necessary  for  the  best 
use  of  vacuum  cleaners. 


*The  School  Board  Journal  above  referred  to  has  many  advertise- 
ments and  cuts  of  various  makes,  and  any  school  system  can  easily  get 
the  chance  to  try  out  any  number  desired.  Such  experimentation  is 
desirable  before  purchasing. 


284     SCHOOL  HEALTH  ADMINISTRATION 

SANITARY  SCHOOL  DESKS  AND  SEATS 
Real  educational  school  desks  will  probably  be,  as  in 
the  University  of  Chicago  model  school,  work  benches  or 
combination  working  desks,  movable,  adjustable  and  with 
movable  seats.  Such  desks  are  not  used.  The  usual  type 
has  four  or  more  legs  close  to  the  floor  and  screwed 
down.  This  is  the  child's  stationary  stall,  for  silent,  seden- 
tary, bookish  work.  It  does  not  meet  the  needs  of  the  all- 
around  school  life.  However,  there  are  school  desks  and 
seats  that  have  all  the  disadvantages  of  being  stationary  and 
fixed,  and  without  some  of  the  "new-fangled  notions"  of 
combination  work-bench-desk,  but  having,  alas,  the  quality 
of  being  adjustable  to  the  child,  that  can  be  swept  under 
and  kept  in  sanitary  condition.  I  refer  to  the  oval  base, 
single-pedestal  combined  seat  and  desk  invented  by  a  Boston 
janitor  and  improved  upon  and  sold  in  the  market  by  a 
well-known  seating  firm.  Here  is  only  one  pedestal  for 
each  child  in  the  room  instead  of  four.  When  poorly  put 
down  they  become  "wobbly,"  and  the  boy  in  front  can  spoil 
the  writing  of  the  boy  behind,  but  this  insecurity  is  unnec- 
essary. The  Moulthrop  movable  school  chair  is  also  be- 
coming popular. 

Adjustable  desks  were  used  in  only  a  part  of  the  cities 
and  in  only  a  part  of  the  schools.  A  city  may  reply  to  a 
questionnaire  that  it  uses  adjustable  desks  and  have  only 
a  few  in  use.  This  is  a  weakness  of  the  investigation  re- 
ported in  Chapter  Two. 

In  Boston,  the  School  House  Commission  has  always 
been  in  the  lead  of  most  cities  in  problems  of  school  archi- 
tecture and  sanitation.  It  has  done  most  in  the  way  of 
devising  the  proper  kinds  of  windows  in  south-exposed 
rooms,  for  open-air  rooms.  It  also  sent  a  deputation  to 
Chicago  to  study  open-window  and  open-air  schools  there, 
"with  little  profit."  It  has  also  done  most  in  the  study 
of  humidifying  the  school  atmosphere,  and  the  lack  of 
agreement  among  experts  in  ventilation  consulted  has  al- 
most brought  matters  to  a  standstill  until  the  problem  is 
less  obscure.  There  are,  however,  examples  of  humidifiers 


DIVISIONS  OF  HYGIENE  285 

and  regulators  that  seem  to  work  to  great  advantage,  as 
at  the  Horace  Mann  School,  Teachers  College,  Columbia 
University.  A  steam  pan  is  used,  and  several  barrels  of 
water  are  sometimes  used  in  a  day  in  keeping  up  a  55  per 
cent  saturation,  and  a  65  degree  class-room  temperature, 
all  automatically  regulated  by  wet  bulb  and  dry  bulb  humidi- 
ometers  by  the  Johnson  Service  Company. 

FLOOR  OILS 

Floor  oils  are  quite  commonly  used,  and  are  bought  for 
from  ten  cents  to  more  than  a  dollar  a  gallon.  Experiments 
and  analyses  at  Rochester  and  try-outs  at  West  Orange 
seemed  to  show  that  there  was  little  difference  between  oil 
of  the  two  prices.  A  city  could  get  about  the  same  oil  for 
the  price  it  wished  to  pay.  We  very  much  need  adequate 
experimental  testing  of  many  more  or  all  of  the  various 
kinds  of  school  supplies  and  equipment.  We  need  better 
use  and  test  of  what  we  get,  as  well  as  "more  money  for 
public  schools." 

Oil  carefully  put  on,  left  to  dry,  and  then  wiped  off  with 
cloths,  during  a  two  or  more  days'  vacation  has  in  a  more 
or  less  scientific  manner  been  found  very  desirable  in  keep- 
ing schools  clean,  and  little  complaint  from  women  teach- 
ers about  their  skirts  have  arisen.  In  the  writer's  own 
school  the  women  teachers  voted  to  have  oiling  stopped, 
but  after  an  experiment  of  three  or  four  weeks  voted  to 
have  it  renewed.  The  matter  has  been  tested  out  in  various 
ways.  We  need  a  careful  experimental  and  adequately  con- 
trolled test  of  the  whole  method.  Some  insist  on  bare  floors, 
others  on  oiled  floors.  Differences  in  floors  and  jani- 
tors count,  but  the  matter  can  be  comparatively  and  experi- 
mentally proved. 

DUST  ABSORBING  COMPOUNDS  AND  SPRAYS 

It  is  remarkable  what  a  variety  of  products  are  used 
in  this  field.  It  is  encouraging  to  see  something  of  the 
kind  used,  but  again  we  have  little  proof  of  the  value  of 
any  one  kind  over  others.  About  twenty  of  the  cities  used 


286     SCHOOL  HEALTH  ADMINISTRATION 

damp  sawdust  or  one  or  more  of  the  various  kinds  of 
no-dustos,  dustalines,  no-more-dust,  sprays  (Rihac),  etc. 
What  must  be  had  is  the  experimental  testing  of  these 
expensive  theories.  Perhaps  damp  sawdust  is  sufficiently 
efficient.  Perhaps  it  would  be  cheaper  to  put  in  vacuum 
cleaners.  Perhaps  oil  brushes  are  better.  Who  knows? 

PAPER  VS.  CLOTH  TOWELS 

Paper  towels  seem  easily  to  be  winning  out  over  the  old 
common  cloth  towel.  Many  cities  were  trying  them,  and 
some  cities,  like  New  Bedford,  Montclair  and  others,  had 
definitely  adopted  them  for  all  children.  They  are  now 
so  cheap,  so  thoroughly  individual,  so  sanitary,  and  so 
effective,  if  well  chosen  through  experimental  testing,  that 
there  is  no  longer  any  excuse  for  the  old,  indecent,  filthy 
and  generally  de-educating  lack  of  proper  sanitary  neces- 
sities yet  so  common.  We  teach  and  preach  to  our  children 
in  the  classrooms  about  the  dangers  of  carriers  and  Typhoid 
Marys,  and  then  fail  to  provide  conditions  which  will  make 
possible  the  acquisition  of  anti-Typhoid  Mary  habits  in  our 
class  and  toilet  rooms.  Every  child  should  have  warm 
water  with  which  to  wash  his  hands,  liquid  soap  for  the 
inevitable  grime  of  the  real  playground  and  real  boy,  good 
absorbent  paper  towels,  satisfactory  arrangements  for 
plenty  of  good  drinking  water  obtained  without  danger  to 
life  and  limb ;  clean,  well-equipped  and  sufficient  toilet  facili- 
ties, a  drying  and  warming  place  for  himself  and  his  clothes 
when  he  comes  wet  and  cold  to  school  (perhaps  without 
breakfast,  or  one  of  only  coffee  and  bread),  a  place  to  clean 
his  shoes  and  insistence  on  it,  a  place  to  hang  his  clothes 
that  is  warm  and  dry  and  supplied  with  hooks  that  keep 
the  clothing  and  possible  contagion  far  apart  instead  of 
huddled  together  for  the  benefit  of  scarlet  fever,  diphtheria 
and  very  much  larger  germs.  The  only  kind  of  health 
knowledge  and  hygiene  for  our  pupils  is  the  kind  that  will 
eventuate  in  adequate  health  habits,  and  how  many  schools 
even  fairly  meet  the  simple  essential  sanitary  standards 
above  named?  Entirely  too  few. 


DIVISIONS  OF  HYGIENE  287 

We  must  close  the  report  of  this  division.  Better  sani- 
tation is  approaching  slowly,  and  for  its  slowness  there  is 
a  reason,  convincing  to  the  writer,  and  to  be  given  at  the 
end  of  the  chapter. 

C.    The  Teaching  of  Hygiene. 

We  meet  the  same  situation  in  the  field  of  the  teaching 
of  hygiene,  a  form  of  knowledge,  habits  and  ideals  much 
more  important  in  the  modern  world  than  probably  three  or 
four  entire  subjects  now  tremendously  emphasized  ufor 
their  formal  disciplinary  value"  in  our  high  schools  and* 
probably  one  or  two  in  our  elementary  schools.  And  yet 
the  subject  is  a  tail-end  subject,  little  emphasized,  and  fur- 
nished with  poor  textbooks  for  the  most  part  and  very 
frequently  with  poor  teachers  in  the  grades  or  high  school. 
Colleges  do  not  generally  give  credit  for,  nor  demand  a 
knowledge  of,  this  vitally  essential  subject  of  health  and 
how  to  get  and  maintain  it,  much  to  their  disparagement, 
and  consequently  we  find  many  schools  almost  entirely 
neglecting  it.*  And  yet  the  cadets  march  by,  with  sunken 
chest  and  defective  eye,  all  but  those  who  have  dropped 
by  the  wayside  through  death  and  illness;  and  the  medical 
inspectors  continue  to  report  their  ailments  by  the  thousands. 
The  problems  of  the  people  are  the  problems  of  education. 
Health  is  a  prime  problem,  and  health  knowledge  measuring 
up  to  our  needs  today  is  one  of  those  alphabetic  concepts 
which  every  child  must  have  whether  he  ever  sees  a  gram- 
mar or  an  algebra  or  a  Caesar  or  a  geometry  or  a  moderr 
foreign  language  in  his  life. 

Health  teaching  is  in  these  cities  evidently  "seriously 
defective,"  in  the  words  of  the  New  York  School  Inquiry 
Report,  and  most  educators  today  are  realizing  it  and 
gradually  beginning  to  introduce  pragmatic  changes. 

I  learned  in  most  cities  how  much  time  was  given  to 
the  subject  of  hygiene  in  all  grades,  elementary  and  high 
schools,  and  the  texts  used.  We  shall  not  repeat  here  the 
names  of  many  of  the  texts.  In  the  older  days  of  logic,  all 


*See  Johnston's  High  School  Education,  volume  one. 


288     SCHOOL  HEALTH  ADMINISTRATION 

our  subjects  began  with  the  anatomy  of  the  subject,  the 
dry-bones,  so  to  speak,  the  formal  grammar,  the  letters,  the 
parts  of  a  letter  in  penmanship,  celestial  mechanics  in  geog- 
raphy, the  bones  of  arithmetic,  etc.  One  of  the  old  books 
on  "Anatomy  and  Physiology  for  Children,"  or  some  such 
title  actually  started  out  with  a  chapter  entitled,  "Dry 
Bones,"  and  all  the  206  with  their  good  points  were  to  be 

4  learned  by  heart,  with  never  a  mention  of  how  to  live 
healthily  and  happily  in  this  world.  Then  came  the  physi- 
ology period,  when  we  learned  some  anatomy  and  much 
of  the  chemistry  of  digestion  and  respiration,  etc.  Today 
the  subject  is  at  last  becoming  socialized  and  changed  from 
a  logical,  abstract  science  to  a  vitally  essential  scientific  art, 
ministering  to  the  health  needs  of  our  people.  Some  of 
these  older  texts  are  still  being  used  in  the  cities  visited, 
and  in  very  few  of  the  cities  in  elementary  or  high  school 
is  the  subject  given  the  time  and  texts  which  its  known 
value  warrants  and  demands. 

t  The  Ritchie  Hygiene  series  and  that  by  Gulick  and  Jewett 
seem  at  present  to  be  in  advance  of  all  others.  We  found 
them  used  in  but  ten  cities.  In  most  of  the  other  cities 
where  I  had  an  opportunity  to  talk  with  the  superintendent 
on  the  matter  of  school  hygiene  texts,  I  found  books  from 
one  of  these  two  suggested  series  either  ordered,  about  to 
be  ordered,  or  actually  being  experimentally  tried  out  in  a 
few  rooms.  Probably  a  search  of  the  present  book  lists  of 
these  cities  would  show  better  supplies  of  more  modern  texts. 
One  subject  of  great  importance  but  little  taught  is  that 

,  of  industrial  hygiene.     Another  is  sex  hygiene. 

Teachers  are  not  adequately  trained  in  this  subject  in 
most  normal  schools  and  consequently  have  not  the  interest 
in,  or  such  a  knowledge  of,  the  subject  as  is  desirable. 
Lacking  health  education,  and  in  their  comparative  isola- 
tion from  the  problems  of  life,  we  find  that  they  cannot 
clearly  see  "what  knowledge  is  of  most  worth"  to  their 
pupils.  The  modern  world  is  becoming  aware  of  its  health 


NOTE. — Colton's   new   book   on    "The    People's    Health"    by   Mac- 
millans  is  a  very  valuable  contribution  to  upper-grade  texts  in  hygiene. 


DIVISIONS  OF  HYGIENE  289 

heritage  and  health  knowledge  now  possessed  by  but  a  few 
is  rapidly  coming  to  be  democratized,  so  we  may  expect 
soon  the  most  rapid  changes  toward  meeting  the  real  needs 
of  real  life.  Good  textbooks  are  indispensable  for  the 
best  results  for  American  teachers  in  general,  and  their 
selection,  as  well  as  the  time  allotment,  are  matters  for 
close  study. 
D.  The  Hygiene  of  Teaching. 

This  division  of  educational  hygiene  is  usually  called 
"the  hygiene  of  instruction,"  but  instruction  is  only  a  part 
of  the  teacher's  work  and  the  life  of  the  school.  The 
French  are  wont  to  contrast  instruction  and  education.  The 
German  or  French  teacher  instructs  all  his  classes  all  day 
long.  The  American  teacher  gives  time  for  individual 
study,  self-help,  and  individual  guidance,  for  teaching  in 
the  best  sense,  and  so  we  use  the  term,  the  Hygiene  of 
Teaching. 

A  teacher  may  teach  hygiene  for  such  long  periods  or 
in  so  dryland  dismal  a  way  as  to  over-fatigue  and  depress 
her  pupils.  She  may  teach  splendidly  the  subject  of  tuber- 
culosis in  a  school-room  with  all  windows  tightly  closed  and 
the  air  so  thick  and  vile  that  little  lungs  easily  become  sus- 
ceptible to  the  germs  she  teaches  the  children  to  dread. 
She  would  have  taught  better  had  she  opened  her  windows 
in  a  proper  manner.  Again  she  may  be  teaching  quite  effec- 
tively, from  the  intellectual  side,  the  hygiene  of  vision,  and 
yet  the  print  of  the  books  she  has  placed  in  her  pupils'  hands 
may  be  so  atrocious  that  most  children  suffer  from  eye- 
strain  after  the  study  period;  or  again  her  curtains  may  be 
so  arranged  that  with  well  printed  books  and  good  teaching, 
she  may  be  injuring  her  pupils'  eyes  by  bad  lighting,  while 
discussing  the  danger.  All  these  are  mistakes  in  the  hygiene 
of  teaching  and  there  are  multitudes  more  which  the  un- 
hygienically  trained  teacher  will  make  continually  in  any 
few  days  of  time. 

Other  topics  in  this  field,  but  not  studied  in  the  inves- 
tigation because  of  the  room-to-room  character  of  the  work, 
are :  fatigue,  school  program,  one  session  or  two  sessions,  * 


29o    SCHOOL  HEALTH  ADMINISTRATION 

recesses  or  no  recesses,  rest  periods,  the  type  of  books,  the 
adjustment  of  the  daily  surroundings  of  pupils  to  their 
bodily  needs,  the  health  results  of  marks  and  examinations, 
the  teacher's  responsibility  for  the  increase  of  defects  of 
vision,  for  choreic,  anemic  and  debilitated  children,  the 
development  of  healthful  habits  and  interests,  and  ways  of 
study  and  doing  work;  in  general,  the  most  harmonious 
guidance  of  the  school  life  of  the  pupil  and  his  fellows,  in 
order  that  there  may  be  a  real  hygiene  of  living,  a  hygiene 
that  "will  make  growth  more  perfect,  life  more  vigorous, 
decay  less  rapid,  death  more  remote." 

CONCLUSIONS 

In  this  chapter  we  have  taken  a  rapid  survey  of  the 
last  four  divisions  of  educational  hygiene  as  practiced  in 
these  cities,  and  as  they  should  have  been  practiced.  We 
have  found  them  in  a  transitional  stage  and  changing  in  a 
few  years  from  a  more  static,  isolated  attitude  toward  the 
problems  of  school  health,  to  a  more  socialized,  scientific 
and  democratic  attitude.  Some  of  the  cities  will  probably 
be  little  further  advanced  in  the  next  decade,  but  the  most 
of  them  will  before  long  undoubtably  make  most  of  "the 
things  hoped  for"  an  actual  realization. 

The  principal  drawback,  as  I  see  it,  is  neither  the  lack 
of  money  nor  the  backwardness  of  the  people  and  the 
superintendent,  but  in  the  gap  existing  in  practically  each 
school  system  that  should  be  filled  by  a  person  specially 
intelligent,  responsive  and  able  in  health  matters.  The 
ordinary  superintendent  probably  does  not  give  a  large 
fraction  of  one  per  cent  of  his  time  and  energy  to  the  prob- 
lems of  educational  hygiene.  He  and  his  supervisors  and 
his  teachers  are  otherwise  engaged.  The  intellectual  aspects 
of  life  are  those  which  absorb  his  and  teachers'  energies. 
He  appreciates  somewhat  the  health  needs  but  he  does  not, 
or  can  not,  take  time  for  them.  The  solution  of  the  health 
problem  in  the  schools  will  come,  as  we  have  seen  all  along 
throughout  the  book,  only  in  the  appointment  of  a  thor- 
oughly qualified  man,  educated  in  medicine  and  school  hy- 


DIVISIONS  OF  HYGIENE  291 

giene,  and  given  the  entire  management  and  responsibility 
for  the  health  aspects  of  education.  Only  then,  I  believe,  will 
health  become  a  reality  in  our  schools,  and  educational 
hygiene  now  in  its  infancy  become  a  scientific  art. 

The  following  chapter  brings  all  the  suggestions  of  the 
book  together  in  the  form  of  a  rather  detailed  and  prac- 
tical plan  for  reaching  this  much-to-be-desired  goal,  in  the 
adequate  administration  and  reorganization  of  all  the  divi- 
sions of  educational  hygiene. 


HEALTH   EFFICIENCY  THROUGH   NOR- 
MAL EDUCATION 

With  the  increasing  socialisation  of  education 
we  may  look  forward  toward  a  more  normal 
mental  and  physical  life  for  school  children.  The 
older  methods  of  sentencing  growing  children  for 
many  years  to  sedentary  book-reading  in  sta- 
tionary seats  are  beginning  to  pass  away.  Chil- 
dren are  no  longer  looked  upon  by  the  best 
teachers  and  administrators  as  mere  disembodied 
mentalities,  but  school  life  is  becoming  an  all- 
round  life  largely  consisting  of  useful,  socialising 
and  energising  motor  work  and  play.  The  school 
grounds  are  becoming  community  parks  and 
recreation  centers  taking  the  place  of  the  village 
green  of  the  olden  times;  the  school  building  is 
being  transformed  into  a  house  of  childhood  ade- 
quately adapted  to  the  real  nature  of  children  and 
the  needs  of  society;  and  the  old  Greek  spirit  of 
all-round  joyous  efficiency  is  coming  by  a  new 
birth  again  into  its  own..  We  need  many  more 
experimental  schools  that,  like  Tuskeegee,  Abbots- 
holme,  Inter-laken,  and  the  various  consolidated 
farm  schools,  will  lead  the  way  into  this  broader 
and  less  artificial  education.  Health  efficiency 
through  normal  living  is  an  actual  possibility. 


292 


PART   THREE 

THE  ADMINISTRATION  OF  MEDICAL  INSPECTION 


(Part  three  may  also  be  had  in  separate  pamphlet 
lorm  for  the  use  of  teachers,  nurses,  doctors,  etc.  The 
blank  forms  herein  described  may  be  purchased  in 
quantities  from  the  publishers,  Teachers  College,  Co- 
lumbia University,  Publication  Department,  New 
York  City.) 


293 


ENLARGING    SCOPE    OF   THE   SCHOOL 

"The  complete  pedagogy  of  the  future  when 
it  comes  will  be  larger  than  it  has  yet  entered 
into  the  heart  of  any  man  to  conceive.  Thus  the 
present  situation  should  appeal  to  the  best  young 
men  as  education  has  never  before  appealed.  All 
the  four  or  five  score  of  child-helping-welfare 
agencies  must  and  will  be  correlated  with  the 
school  and  directed  from  one  central  bureau,  so 
that  each  child  can  be  placed  just  where  in  the 
whole  system  it  will  get  the  most  good.  Each, 
too,  will  not  only  be  inspected  medically  and 
morally,  but  studied  for  vocational  aptitudes." — 
G.  Stanley  Hall,  in  Introduction  to  (( Educational 
Problems." 


294 


CHAPTER  ELEVEN 
THE  ADMINISTRATION  OF  MEDICAL  INSPECTION 

A  TENTATIVE  STANDARD  PLAN 

I.    GENERAL    ORGANIZATION 

A.  Each  school  system  able  to  afford  it,  and  few  can- 
not, should  have  an  organized  Department  of  Hygiene, 
with  a  Supervisor  of  Hygiene,  correlative  with  other  super- 
visory departments  in  the  schools.  It  should  be  called  the 
Department  of  Hygiene  to  avoid  confusion  with  the  depart- 
ment of  health  of  the  city.  It  need  not  be  entitled  the 
"Department  of  School  Hygiene"  for  the  same  reason  that 
the  department  of  drawing  is  not  called  the  department  of 
school  drawing.  Neither  need  it  be  called  the  "Department 
of  Hygiene  and  Physical  Training"  nor  any  other  such 
combination.  The  word  Hygiene  is  as  broad  as  Health 
and  may  be  used  to  cover  all  health  agencies  of  the  public 
schools,  namely: 

1.  Medical  Inspection. 

2.  Physical  Education. 

3.  School  Sanitation. 

4.  The  Teaching  of  Hygiene. 

5.  The  Hygiene  of  Teaching. 

The  function  of  such  a  department  is  to  coordinate  and 
make  efficient  through  organization,  inspiration,  and  super- 
vision all  the  heterogeneous  agencies  for  the  promotion  of 
the  health  and  normal  physical  development  of  the  school 
children. 

SCOPE 

A  large  number  of  the  more  or  less  neglected  problems 
of  school  health  and  national  vitality  would  thus  come 
within  the  scope  of  this  department,  among  which  may  be 

295 


THE  DIVISIONS  OF  EDUCATIONAL 

HYGIENE 

Supervisor  of  Hygiene 


MEDICAL 
SUPERVISION 

SCHOOL 
SANITATION 

PHYSICAL 
EDUCATION 

TEACHING 
HYGIENE 

HYGIENIC 
TEACHING 

NURSES        AND 

SCHOOL     SITES 

PLAY   AND 

HEALTH     EDU- 

"THE    HYGIENE 

DOCTORS. 

AND     ARCHI- 

PLAYGROUNDS. 

»  CATION    OF 

OF    INSTRUC- 

TECTURE. 

TEACHERS. 

TION." 

INSPECTIONS 

PHYSICAL 

AND        ANNUAL 

VENTILATION. 

TRAINING 

ADVISING 

FATIGUE, 

EXAMINATIONS 
SCHOOL 

LIGHTING. 

AND     GYM- 
NASTICS. 

CHOICE     OF 
,  BEST    HYGIENE 
^TEXTS    AND 

OVER-WORK 
AND    UNDER- 

"\\7f\T)  If 

CLINICS. 

HEATING. 

MEDICAL 

TOPICS. 

W  UirCxv. 

HEALTH 

T\T>  T  "NT  "K"  T  "NTT1 

GYMNASTICS. 

FORMING 

THE    TYPE    OF 

CENSUS. 

Urvll\li\.llNljr 

WATER    AND 

ATHLETICS           4 

PERSONAL 

TT-VT/-*  TTr'XTTj^ 

BOOKS. 

DISCOVERING 

FOUNTAINS. 

AND     LEAGUES./ 

Xi  1  IjTlUjIN  XlJ 

HABITS. 

<fTHE     HYGIENE 

HEALTH 

NEEDS. 

SCHOOL 
CLEANING. 

POSTURE     AND 
CORRECTIONAL, 

PUBLIC 
•  HYGIENE 

OF    SCHOOL 

SUBJECTS.                ' 

CO-OPERATING 
WITH      BOARDS 
OF    HEALTH 

VACUUM 
CLEANERS. 

EXERCISES. 
ASSISTING 

STUDY    AND 
CO-OPERATION. 

INTEREST    AND 
ATTENTION. 

AND     PRIVATE 
ORGANIZA- 
TIONS. 

SCHOOL 
BATHS. 

IN    MEDICAL 
SUPERVISION. 

HEALTH  EDU- 
.  CATION    OF 
PARENTS. 

INTER-RECI- 
TATION   RE- 
CREATION. 

OPEN    AIR 
SCHOOLS. 

LIMITING 
DOCTORS    TO 
EXAMINA- 
TIONS, 

HYGIENIC 
TOILET 
FACILITIES. 

SCHOOL     SEATS 
AND    DESKS. 

RECREATION. 

SCHOOL 
EXCURSIONS 
AND     TRAMPS. 

BOY     SCOUTS 

FEEDING, 
CLOTHING 
AND     SLEEP 
OF     CHILDREN. 

HOME  HYGIENE 
'IN    DOMESTIC 

TRANSFORM- 
ING    NEURAS- 
THENIC   AND 
"CRANKY" 
TEACHERS. 

SUPERVISION 
OF    NURSES 
AND    WORK 
IN   CLINICS. 

PSYCHOLO- 

DECORATION. 

THE     STAND- 
ARD    SCHOOL 
ROOM. 

AND    CAMP 
FIRE     GIRLS. 

GYMNASIUMS 
AND    ATHLETIC 
FIELDS. 

SCIENCE. 

VOCATIONAL 
.  HYGIENE     IN 
INDUSTRIAL 
SUBJECTS. 

MO.TOR 
ASPECTS     OF 
TEACHING. 

THE    GOSPEL 
OF  WORK. 

GISTS, 
OCULISTS, 
SURGEONS, 

FIRE-PROOF 
CONSTRUC- 
TION. 

SWIMMING 
AND     BATHING. 

TALKS    BY 
DOCTORS, 
NURSES    AND 

THE     HYGIENE 
OF     JOY     IN 

DENTISTS, 
PHYSICIANS. 

HEALTH,  REST, 

POOLS,     SHOW- 
ERS   AND 

SPECIALISTS. 

SCHOOLS. 

SUPERVISION 
OF     SCHOOL 

AND     EMER- 
GENCY    ROOMS. 

BEACHES. 
FOLK 

FIRST     AID. 
".  SEX     HYGIENE. 

PREVENTING 
PHYSICAL 
DEFECTS     AND 

FEEDING. 

PLAYROOMS 

DANCING. 

.  STUDYING 

PATHOLOGICAL 

SCIENTIFIC 

AND    ROOF 
PLAYGROUNDS. 

PHYSICAL 

COMMUNITY 
HEALTH 

CONDITIONS. 

STUDIES    OF 

EDUCATORS 

PROBLEMS 

SCHOOL 

PREVENTION 

OPEN    WINDOW 

WITH   MEDICAL 

AND     METHODS 

PROGRAMS. 

AND     CAUSE 
OF    DISEASE. 

ROOMS. 

KNOWLEDGE. 

OF    IMPROVE- 
MENT. 

PART-TIME     OR 

CAREFUL 
RECORDS 
EMPHASIZING 
SERIOUS 
AILMENTS 
FOUND    AND 

SUPERVISION 
OF     JANITORS. 

HYGIENIC 
CLQ^K    ROOMS. 

HIGH     SCHOOL 
CADETS. 

CLASS    ROOM       . 
GAMES. 

PAY   FOR 

DAILY   ORAL 
QUESTION- 
NAIRE   ON 
HOME 
HYGIENE  : 
USE    OF 

WHOLE-TIME. 

INFLUENCE 
OF    VACA-                 i 
TIONS  AND 
HOLIDAYS. 

CURED. 

DRYING    AND 

SUPERVISING 

TOOTH-BRUSH, 

HEALTH    IN- 

TRAINING 
SCHOOL 
NURSES    FOR 
ALL    INSPEC- 
TION   AND 
EXAMINATION. 

WARMING 
SEATS. 

INVESTIGA- 
TIONS  OF  RE- 
CIRCULATION, 
HUMIDITY, 

PLAY   AFTER 
SCHOOL    AND 
SATURDAYS. 

CULTIVATING 
THE    GREEK 
IDEAL    OF 

COFFEE 
DRINKING, 
VENTILATION, 
ETC. 
HEALTH 
KNOWLEDGE, 
HEALTH 

DIVIDUALITY. 

HYGIENIC 
EFFECTS     OF 
DIFFERENT 
METHODS. 

NURSES    AS 

AIR-CLEAN- 

PHYSICAL 

IDEALS, 

THE     TEACHER 

ATTENDANCE 

ING,    DISIN- 

AND    MENTAL 

HEALTH 

AS    MEDICAL 

OFFICERS. 

FECTION,   ETC. 

PERFECTION. 

EFFICIENCY. 

GUARDIAN. 

MEDICAL  INSPECTION  PLAN  297 

named:  *  play  and  playgrounds,  selection  of  school  sites 
and  special  phases  of  school  architecture  from  the  hygienic 
standpoint,  pure  water,  school  cleaning,  gymnasiums,  ven- 
tilation, heating  and  lighting,  athletics,  physical  training, 
summer  playgrounds,  evening  recreation  centers,  selection 
of  textbooks  for  the  teaching  of  hygiene,  the  print  of  books, 
problems  of  fatigue  and  school  programs,  home  study, 
proper  seating,  feeding  of  the  under-nourished,  open-air 
and  open-window  schools,  the  work  of  school  doctors, 
nurses,  dentists,  oculists,  and  the  school  clinics,  co-operation 
with  dispensaries,  hospitals,  infirmaries  and  private  bodies 
desiring  to  aid  school  health  work,  and,  finally,  the  educa- 
tion of  the  public  along  all  lines  of  educational  hygiene  and 
the  care  of  school  children. 

B.  The  Director  of  Hygiene  should  be  a  doctor  of 
educational  hygiene,  or  a  doctor  of  public  health  (D.  P. 
H.)  Lacking  training  colleges  for  such  men  as  yet,  a 
physician  who  is  a  specialist  in  children's  diseases  and  who 
has  made  a  special  study  of  the  science  and  practice  of 
educational  hygiene,  at  least  of  physical  education,  and  has 
had  successful  experience  in  it,  should  (by  competitive 
examination)  be  selected.  A  number  of  physicians,  qualified 
fairly  well  by  study  and  successful  experience  in  school  sys- 
tems, colleges,  normal  schools,  Y.  M.  C.  A.'s  and  children's 
hospitals  and  clinics,  are  at  present  available  at  salaries 
from  $2,000  to  $4,000  a  year,  and  the  demand  will  lead 
to  an  adequate  future  supply.  Several  cities  now  have 
such  directors.  After  a  brief  search  the  writer  has  found 
twenty  men  qualified  and  available  for  such  work. 

The  health  of  the  children  of  the  schools  and  nation 
will  not  be  adequately  preserved  and  protected  until  such 
a  definite  organization  and  such  health  leaders  are  incor- 
porated in  school  systems.  Efficient  leadership  furnishes 


*See  elaboration  of  these  phases  in  Hygiene  and  Physical  Educa- 
tion, for  June,  1909,  in  The  Progressive  Journal  of  Education  for 
September,  1909,  American  Education  'for  April  1912,  Education  for 
December,  1912,  in  School  and  Home  Education  for  May,  1912,  and  in 
The  Journal  of  Education  for  February  27,  1913. 


298     SCHOOL  HEALTH  ADMINISTRATION 

that  scientific  management,  inspiration,   and  breath  of  life 
necessary  in  all  successful  social  organization,  and  the  school 
cannot  afford  longer  to  miss  its  advantages  in  the  funda- 
mental field  of  health. 
C.  Scientific  Organization  with  Little  Increased  Expense. 

The  expenditure  for  such  a  Supervisor  of  Hygiene,  in 
cities  that  already  are  doing  their  duty  to  the  children  in 
the  line  of  health,  with  school  doctors,  nurses  and  physical 
training  teachers,  frequently  may  require  little  or  no  addi- 
tion to  the  present  school  budget,  the  work  being  merely 
that  of  reorganization  of  the  various  health  provisions 
which  have,  in  various  ways  and  for  several  years,  been 
coming  into  the  school  systems.  In  all  but  the  largest  cities 
the  director  can  take  the  place  of  one  or  more  part-time 
physicians,  and  can  also  do  the  work  of  one  or  more  super- 
visors, or  teachers,  of  physical  training  in  the  elementary 
schools.  Money  can  also  be  saved  by  having  him  direct  the 
summer  playground  work  which  now  costs  a  number  of 
cities  considerable  sums,  the  school  clinic  or  clinics  when 
started,  high  and  elementary  school  athletics,  evening  recre- 
ation, and  a  number  of  other  savings  which  may  go  to 
make  up  his  salary.  The  nurses,  when  so  directed,  may 
take  the  places  of  attendance  officers  in  many  cities  and 
so  save  another  considerable  item. 

The  present  expenditures  in  these  fields  and  the  reorgan- 
ized expenditures  have  been  given  in  preceding  chapters 
and  tables.  Most  cities  have  not  yet  caught  up  with  the 
school  health  needs;  but  most  cities  of  average  size  can 
secure  such  departments  of  hygiene  for  little  over  two  to 
three  per  cent  of  current  school  expenditures.  In  many, 
the  added  expense  will,  as  suggested,  be  inconsiderable. 

For  further  concreteness,  the  old  and  the  new  reorgan- 
ized expenditures,  for  a  fairly  typical  city  already  possess- 
ing the  elements  of  such  a  department,  are  here  given. 
This  city  has  a  population  of  about  50,000;  there  are  15 
schools,  a  public  school  average  enrollment  of  6,000  pupils; 
and  annual  current  expenditures  amounting  to  about 
$250,000. 


ijfc^  \J^ 

MEDICAL  INSPECTION  PLA^  299 

OLD,  UNCORRELATED  SYSTE1 

2  high  school  teachers  of  physical  training /. $2,200 

2  elementary  school  teachers  of  physical  trainingy: 1,800 

6  physicians,  two  one-hour  school  visits  weekly./at  $300 1,800 

3  school  nurses,  44  hours  a  week,  at  $$AA,  ten/months 2,250 


Total    $8,050 

RE-ORGANIZED,   DIRECTED   SYSTEM 

1  supervisor  of  hygierle,  full  time,  n  months $3,OOO 

2  high  school  teachers  of  physical  education 2,2OO 

I  assistant  physician,  two  hours  a  day,  ten  hours  a  week 4Qft 

3  school  nurses,  44  hours  a  week,  2  at  $825*  I  at  $750 2,400 


Total    $8,000 

Here  we  have  the  new  organized  and  directed  system 
at  less  than  the  original  cost.  There  remain  fifty  dollars 
toward  more  efficient  records  and  blank  forms.  We  have 
deducted  nothing  for  saved  expenditures  for  attendance  offi- 
cers, playground  direction,  etc.,  nothing  but  five  unneces- 
sary part-time  physicians  and  the  two  elementary  teachers 
of  physical  training.  Where  the  latter  officials  are  paid 
less  in  the  old  system  and  the  supervisor  $2,500  instead 
of  $3,000,  there  is  another  balancing  of  expenditures.  The 
point  is  that  the  added  expense  need  not  be  great. 

The  third  nurse  may  not  be  added  the  first  year,  which 
would  give  a  further  reduction  of  $750.  Perhaps  scientific 
management  may  make  her  permanently  unnecessary  in 
many  cities. 

The  supervisor  can,  with  the  daily  help  of  one  of  the 
two  or  three  nurses,  for  two  hours  a  day,  examine  the  same 
number  of  children  as  the  assistant  physician,  3,000;  and 
he  can  call  the  teachers  together  by  grades  and  teach  them 
how  to  carry  on  the  physical-training  work  at  the  schools; 
and  can  take  part  of  each  day  in  supervising  their  work. 

The  assistant  physician  is  paid  $100  more  a  month,  and 
gives  two  full  hours  in  one  school  daily.  With  the  assist- 
ance of  one  of  the  nurses  he  can  examine  during  the  school 
year  the  other  half  of  the  school  population  (3,000  pupils), 
and  can  help  make  such  inspections  as  are  necessary.  The 
third  nurse,  if  employed,  is  left  free  for  individual  and 


300    SCHOOL  HEALTH  ADMINISTRATION 

class-room  inspections  and  for  follow-up  work.  Neither  the 
teachers  nor  the  physicians  are  bothered  with  vision  and 
hearing  tests,  the  nurses  making  them;  and  practically  all 
clerical  work  connected  with  medical  supervision  will  also 
be  done  by  the  latter.  The  physicians  will  be  free  for  tech- 
nical medical  work,  and  the  teachers  will  be  less  interrupted. 

Two  of  the  nurses  are  paid  for  an  extra  month  in  the 
summer,  one  for  July  and  one  for  August,  to  follow-up 
cases  not  cured  at  the  end  of  the  school  year  and  for  neces- 
sary inspection  of  children  at  summer  schools  and  play- 
grounds. Some  of  the  most  valuable  work  now  being  done 
by  nurses  is  accomplished  in  these  summer  months;  and 
the  number  of  skin,  parasitic,  and  infectious  ailments  is 
very  much  less  at  the  opening  of  the  next  school  year. 

The  two  high  school  teachers  of  physical  training,  one 
a  man  and  the  other  a  woman,  are  left  at  perhaps  the  same 
salaries  ($1,300  and  $900). 

The  supervisor  of  hygiene  gives  his  entire  time  to  the 
work,  not  for  ten  but  for  eleven  months.  If  he  obtains  a 
thoroughly  good  assistant  school-physician,  the  salary  of 
the  latter  may  be  raised  from  $400  to  $500  or  more,  but 
not  sufficient  to  make  possible  the  employment  of  another 
nurse  at  the  same  sum,  perhaps.  It  may  be  well  to  employ 
a  woman  physician  as  part-time  medical  examiner  so  she 
may  better  examine  the  high  school  girls. 

The  trials  and  tribulations  of  the  superintendent  in 
trying  to  get  regular  and  responsible  work  from  part-time 
physicians  and  in  attempting  to  direct  medical  work  without 
medical  knowledge,  are  now  at  an  end.  He  has  a  small, 
compact  and  almost  entirely  full-time  force.  These  are 
essentials.  The  entire  part-time  element  may  yet  be  elim- 
inated, but  it  will  mean  salaries  from  $1,500  to  $2,000,  at 
least,  for  full-time  assistant  physicians. 

Later  developments  of  the  system  can  be  made,  how- 
ever, after  intelligent  study  and  experience.  If  another 
physician  is  desired  he  may  be  obtained,  and  if,  as  the  city 
grows,  an  assistant  in  physical  education  for  the  elementary 
schools  is  found  necessary,  the  addition  can  be  made.  But 


MEDICAL  INSPECTION  PLAN  301 

these  additions  are  intelligent  choices  by  an  expert  in  edu- 
cational hygiene,  after  reasonable  investigation.  We  at- 
tempt to  give  here  only  minimum  essentials  and  suggestions 
for  beginning  or  reorganizing  the  work.* 

For  the  largest  cities,  such  a  health  reorganization  can 
easily  be  made,  and  it  is  practically  possible  for  many  cities 

*At  the  recent  International  Congress  on  School  Hygiene  at  Buffalo 
the  writer  was  given  practically  the  following  facts  by  a  member  of  a 
board  of  education  of  a  typical  New  England  city  (about  9,000  pupils) 
with  a  request  for  a  plan  of  efficient  reorganization: 

PRESENT  "INEFFICIENT"  SYSTEM 

12  part-time  physicians  at  $500 $6,000 

0  nurses    ooo 

2  truant   officers    2,500 

1  elementary  physical  training  teacher 1,000 

I  summer  director  of  playgrounds 150 

$9,650 

This  system,  recognized  by  the  board  of  education  as  inefficient 
and  not  getting  results,  is  a  finely  devised  machine  for  getting  little  more 
than  a  collection  of  pathological  statistics  of  school  population.  The  time 
the  physicians  spend  in  the  schools  is  unknown;  and  they  have  no  super- 
vision nor  nurses  to  follow-up  cases  and  get  treatments  and  cures. 
There  are  no  public  dispensaries  for  free  treatment  of  children,  and  a 
large  share  of  the  population  is  too  poor  to  pay  $20  for  an  adenoid 
operation,  for  example,  or  to  provide  regular  daily  or  weekly  treatment 
for  favus,  ringworm,  discharging  ear,  and  other  ailments.  There  is  enough 
money  being  spent,  however,  to  get  efficient  results  in  this  field.  Leaving 
the  high  school  directors  of  physical  education  in  their  places  at  the 
same  salaries,  we  gave  for  a  beginning  the  following: 

PLAN  OF  REORGANIZATION 

1  supervisor   of  hygiene,    a   physician-physical-educator $2,500 

6  school  nurses,  4  at  $700,  2  at  $770 4,440 

2  part-time  physicians,  two  hours  daily,  at  $500 1,000 

I  school  clinic,  with  dental,  surgical,  and  medical  divisions I,OOO 

I  school  dentist,  with  staff  of  voluntary  dentists 500 

New  blank  forms  for  records  and  reports 210 

$9,650 

Here  we  have  a  vastly  more  efficient  system  at  the  same  expendi- 
ture of  money;  we  have  skilled  leadership  and  supervision;  we  have  a 
plan  which  unifies  all  school  health  agencies ;  and  we  have  the  emphasis 
where  it  belongs,  on  prevention  and  cures.  Necessary  changes  can  be 
made  after  adequate  investigation  by  the  hygiene  supervisor  and  super- 
intendent of  schools. 


302     SCHOOL  HEALTH  ADMINISTRATION 

almost  as  small  as  eight  or  ten  thousand  population.  Sev- 
eral towns  may  even  go  together  and  employ  such  an  expert, 
as  superintendents  are  now  employed  in  several  states.  And 
even  rural  districts  may  unite  in  the  same  way  for  the 
expert  services  of  an  educational  hygienist  and  several 
nurses.  The  great  need  is  for  health  experts  and  for  health 
leadership.  The  people  will  respond  and  act  along  the 
best  health  lines  when  the  health  knowledge,  now  the  pos- 
session of  the  few,  is  made  the  possession  of  the  many. 
We  have  suggested  here  a  possible  channel  for  such  general 
health  enlightenment.  The  far-reaching  influence  of  such 
school  health  leadership  on  national  health  and  vitality  can 
as  yet  hardly  be  imagined. 
D.  Other  Plans  for  the  School  Medical  Service 

Disregarding  as  ineffective  the  physician-alone  plan  for 
school  medical  work,  we  have  two  principal  alternatives 
for  serious  consideration:  the  physician-and-nurse  plan,  al- 
ready suggested,  and  the  nurse-alone  plan.  For  both  there 
is  the  need  of  a  supervising  director  of  hygiene,  unless  the 
superintendent  of  a  small  city  is  exceptionally  well  qualified 
medically  and  has  time  to  devote  to  the  work.  We  need 
supervisors  of  hygiene  as  much  or  more  than  we  need  super- 
visors of  music,  drawing,  and  such  subjects.  For  both  plans 
we  may  have  either  examinations  with  inspection  or  only 
inspection  alone.  We  shall  take  the  stand  that  routine  exam- 
inations, annually,  are  important  as  well  as  inspections.  In 
the  nurse-alone  plan  the  routine  inspections,  with  the  use  of 
individual  cumulative  health  record  cards,  can,  at  first,  take 
the  place  of  complete  medical  examinations,  by  simply 
adding  the  vision  and  hearing  tests. 

The  nurse-alone  plan  is,  in  general,  far  superior  to  the 
physician-alone  plan,  for  a  number  of  reasons,  chief  of 
which  is  that  the  former  gets  treatments  and  cures  for  a 
large  percentage  of  the  cases,  while  the  latter  procures 
treatment  and  cure  for  but  five  or  six  to  twenty  per  cent 
of  the  cases.  Furthermore,  the  nurses  can  find  most  of  the 
cases  of  all  kinds,  and  can  inspect  satisfactorily,  as  proved 
in  New  York,  for  infectious  diseases,  especially  when  under 


MEDICAL  INSPECTION  PLAN  303 

supervision  (September,  1911,  Report  of  Bureau  of  Muni- 
cipal Research).  Cities  as  small  as  Canton,  Mass.,  with 
less  than  five  thousand  population,  and  as  large  as  Oakland, 
CaL,  with  nearly  two  hundred  thousand,  get  good  work  with 
only  nurses,  under  supervision.  (Reports  and  letters  of 
Dr.  Arthur  T.  Cabot  and  of  Dr.  N.  K.  Foster,  respectively.) 
Newark  with  38  doctors  and  8  nurses  is  reversing  these 
figures  by  exchanging  two  doctors  for  each  added  nurse. 
Only  five  or  six  doctors  will  be  kept  as  district  supervisors 
of  the  nurses.  With  the  general  supervisor  as  before  this 
will  greatly  increase  the  efficiency  for  the  money  expended. 
Further,  the  physicians  can  work  but  part-time  while  nurses 
devote  their  entire  time  to  the  work.  The  physicians  are 
irregular  and  difficult  to  control  in  large  numbers,  while  the 
nurses,  with  practically  no  serious  competing  interests,  are 
easily  directed.  And,  finally,  they  are  less  than  half,  and 
frequently  only  one-fifth  as  costly,  hour  for  hour,  and  for 
the  year,  as  physicians.  The  tables  given  in  former  chap- 
ters show  even  greater  disproportions  of  cost  in  a  number 
of  cities,  when  the  annual  number  of  daily  visits,  and  num- 
ber of  hours  each,  are  taken  into  consideration.  Good, 
regular  physicians,  furthermore,  can  spare  little  more  than 
two  hours  a  day  regularly  and  punctually  from  their  prac- 
tice; and  physicians  for  longer  periods  must  be  paid  too 
much  and  cannot  well  stand  the  strain  and  monotony  of 
long-continued  examination  or  inspection.  Diminishing  re- 
turns, with  the  larger  salaries  for  full-time  physicians,  bring 
in  the  school  nurse  often  much  more  efficient  hour  for  hour 
than  such  physicians  as  can  be  obtained.  That  the 
nurses  need  training,  before  and  while  in  service,  and  that 
they  must  have  competent  supervision  is  immediately  appar- 
ent. The  plan  here  outlined,  however,  places  the  emphasis 
upon  the  nurse  and  the  physician,  the  physician-nurse  plan. 
Getting  full-time  work  from  all  school  health  officials  re- 
mains a  nice  problem  for  careful  study  and  local  adjustment. 
The  first  thing  is  to  get  the  hygiene  supervisor,  next  the 
nurses,  and  finally  part  or  full-time  physicians.  A  very  small 
city  unable  to  obtain,  with  $>thers  even,  a  supervisor  should 


304    SCHOOL  HEALTH  ADMINISTRATION 

start  with  a  nurse  rather  than  with  part  time  physicians  if 
possible.     If  only  a  physician  is  employed  the  principal  and 
teachers  must  do  the  follow-up  work.     In  either  case  the 
record  and  report  forms  herein  given  may  be  used. 
E.  Where  to  Obtain  School  Nurses. 

As  with  all  other  forms  of  public  service,  the  success 
of  medical  and  health  work  depends  very  largely  upon  the 
character  of  the  persons  chosen  to  carry  it  on.  The  greatest 
weakness  of  our  school  systems  at  the  present  time  is  due 
to  the  fact  that  our  teachers  are  quite  generally  young 
women  novices  with  a  teaching  tenure  of  three  to  five  years 
only  and  very  largely  ignorant  of  and  inexperienced  in  the 
real  life  of  the  community  and  nation  about  them.  Edu- 
cational readjustment  must  wait  upon  the  improvement  of 
the  character  of  the  teaching  force.  With  even  the  best 
of  supervision  and  the  most  scientific  plans  of  management 
the  health  service  likewise  can  remain  palsied,  feeble  and 
inefficient. 

After  deciding  to  obtain  officials  for  the  school  health 
work,  therefore,  the  practical  problem  becomes  one  of  ob- 
taining high-class  health  agents.  For  nurses,  we  must  as 
yet  depend  very  largely  upon  the  various  training  schools 
for  visiting  nurses,  and  the  visiting  nurses'  associations. 
The  Department1  of  Nursing  and  Health,  under  the  direction 
of  Miss  M.  A.  Nutting,  R.N.,  at  Teachers  College,  Colum- 
bia University,  in  New  York  City,  is  at  present  the  only 
institution  in  the  country  which  gives  instruction  and  train- 
ing for  school  nurses,  and  the  number  who  can  be  supplied 
is  at  present  very  small.  This  is  the  first  source  I  should 
recommend. 

Miss  E.  P.  Crandall,  R.N.,  Executive  Secretary  of  the 
National  Organization  for  Public  Health  Nursing,  52  East 
Thirty- fourth  street,  New  York  City,  and  Miss  E.  L.  Foley, 
R.  N.,  Superintendent  of  the  Visiting  Nurse  Association, 
104  South  Michigan  avenue,  Chicago,  may  also  be  de- 
pended upon  to  advise  school  systems  of  graduate  nurses 
who  are  specially  qualified  for  and  looking  toward  public 
school  work.  Miss  Fannie  F.  Clement,  713  Union  Trust 


MEDICAL  INSPECTION  PLAN  305 

Building,  Washington,  D.  C.,  can  give  valuable  informa- 
tion regarding  the  Red  Cross  Rural  Nursing  Service  and 
persons  available  as  school  nurses.  The  Boston  District 
Nurses  Association  in  affiliation  with  the  Boston  School  for 
Social  Workers,  as  well  as  the  Cleveland  Visiting  Nurses 
Association  in  affiliation  with  Western  Reserve  University, 
and,  finally,  Phipps  Institute  of  Philadelphia  are  also  in 
touch  with  most  nurses  in  the  country. 

The  writer  will  be  pleased  to  send  the  names  of  any 
persons  known  as  qualified  either  as  hygiene  supervisors 
or  as  school  nurses  to  responsible  persons  without  charge 
to  either  party.  Like  Albany,  N.  Y.,  a  city  may  find  in  its 
midst  a  man  qualified  both  as  a  physician  and  a  physical 
educator  for  such  work  and  good  nurses  amenable  to  train- 
ing in  the  school  service. 

II.    THE    DIVISIONS   OF   MEDICAL   SUPERVISION 
The  various  phases  or  divisions  of  the  work  of  medical 
supervision  *  in  this  plan  and,  for  the  most  part,  but  largely 
unrecognized,  in  the  best  systems  now  in  vogue,  are  about 
as  follows: 

A.  Preliminary  clinic,   for  instruction  and  standardization. 

B.  Inspections. 

1.  Pupil  Inspections. 

a.  September   room-inspection   of   all   pupils    by 
doctors  and  nurses. 

b.  Occasional  room-inspections  of  classes  of  chil- 
dren, by  nurses. 

c.  Individual  inspection,  by  teachers,  nurses,  and 
doctors. 

2.  Environmental  Inspections. 

a.  Home  hygiene  inspection,  during  home  visits 
of  nurses. 

b.  Sanitary   inspections   of   the   school  premises, 
by  any  delegated  and  competent  officer. 

C.  Examinations,  complete  physical,  annually  for  all  pupils. 


*The  term  will  probably  remain  medical  inspection,  even  if  it  is  a 
misnomer  in  good  systems. 


306    SCHOOL  HEALTH  ADMINISTRATION 

1.  Scholastic:  vision  and  hearing  examinations,  and  per- 

haps others,  by  the  nurses. 

2.  Medical:  only  those  technical  phases  which  the  nurses 

cannot  do  well,  if  any,  by  doctors. 

3.  Anthropological:   measurements   of   height,    weight, 

chest-expansion  and  the  like,  only  if  required.     Of 
doubtful  value. 

4.  Work  Certificate :  will  probably  not  be  needed  in  well 

conducted  systems. 

D.  Treatment,  Cure  and  Correction. 

1.  By  home  and  family  physicians,  dentists,  or  oculists. 

2.  By  school  nurses. 

3.  By  dispensaries  or  other  free  clinics. 

4.  By  public  school  clinic,  with  various  divisions. 

E.  Prevention. 

By  looking  for  causes,  co-operating  with  other  divisions 
of  educational  hygiene,  and  other  public  and  private 
health  agencies,  and  by  placing  the  emphasis  upon 
preventive  rather  than  merely  curative  agencies. 

How  to  carry  on  efficiently  and  economically  these  dif- 
ferent phases   of  the   work  will   be   the   problem   of   this 
chapter.* 
A.   The  Preliminary  Standardisation   Clinic 

In  the  typical  city  for  which  the  reorganized  expendi- 
tures were  given,  with  a  proportion  of  little  over  three 
per  cent  of  current  school  expenditures  for  the  entire 
department,  including  medical  inspection,  we  have  two  phy- 
sicians and  three  nurses  for  six  thousand  pupils  from  kinder- 
garten through  high  school,  three  thousand  for  each  phy- 
sician (one  the  director),  and  two  thousand  for  each  nurse. 
For  a  city  of  twelve  thousand  children  we  should  have,  of 
course,  twice  as  many  nurses  and  three  assistant  physicians. 
But  no  matter  how  large  or  how  small  the  department  may 
be,  even  one  physician  and  one  nurse,  there  should  be,  when 
they  begin  to  work  together,  and,  if  several,  at  the  begin- 


*For  relative  complete  "Outlines  of  Educational  Hygiene,"  empha- 
sizing medical  supervision,  by  the  writer,  see  Education  for  December, 
1912. 


MEDICAL  INSPECTION  PLAN  307 

ning  of  each  year  or  oftener,  a  meeting  at  which  children 
are  examined  or  inspected,  or  both,  and  standards  for  refer- 
ring cases  to  parents,  for  exclusions,  for  readmissions,  for 
best  methods  of  doing  the  work,  and  the  like,  are  discussed. 
Teachers  and  principals  may  be  present  at  such  meetings, 
and  all  may  take  a  hand  in  coming  to  some  common  agree- 
ment, without  which  there  will,  in  isolation,  develop  the 
greatest  irregularity  among  different  workers  and  frequent 
injustice  to  children  and  parents  through  conflicting  stand- 
ards and  methods. 

This  is  also  the  opportunity  for  the  supervisor  to  outline 
the  work  of  the  year,  and  to  get  suggestions  from  all  con- 
cerned as  to  its  improvement.  It  is  a  time  for  inspiration 
and  education.  All  need  them.  Such  clinics  can  be  held  at 
one  or  more  of  the  several  schools,  if  desired,  or  at  teach- 
ers' meetings,  for  the  purpose  of  giving  the  teachers  neces- 
sary elements  of  child-study  of  a  medical  character,  which 
probably  never  appeared  in  any  course  in  their  professional 
preparation. 

No  city  known  by  the  writer  now  employs  this  means 
for  making  efficient  medical  supervision,  and  he  hopes  for 
its  speedy  experimental  testing.  Besides  these  will  come, 
of  course,  monthly  or  semi-monthly  department  meetings 
which  are  now  quite  common  in  good  systems. 

B.  Inspections 

I.    PUPIL    INSPECTIONS 

a.  September  Class-room  Inspections. — Since  this  plan 
of  administration  gives  the  physician  as  many  pupils  as  he 
can  examine  in  the  entire  year,  beginning  in  September 
about  the  third  week,  and  taking  pupils  in  the  same  order 
each  year,  we  must  provide  what  many  cities  have  been 
driven  to  by  hard  experience,  namely,  a  preliminary,  com- 
plete, routine,  classroom  inspection  of  all  pupils.  With 
3,000  pupils,  each  pair  of  nurses  and  physicians  will  have 
about  75  rooms,  counting  40  pupils  to  a  room.  By  requir- 
ing the  part-time  physicians  to  spend  three  hours  a  day  in 
this  first  general  inspection,  and  with  the  nurses  all  at  the 


308     SCHOOL  HEALTH  ADMINISTRATION 

same  work,  counting  a  classroom,  after  practice,  for  each 
half-hour,  and  records  made,  where  two  work  together, 
we  can  see  that  the  entire  inspection  can  be  made  in  about 
two  weeks.  In  the  case  of  the  two  doctors  and  three  nurses, 
one  nurse  would  have  to  work  alone  at  such  inspections; 
and  in  the  afternoons  when  two  of  the  nurses  worked 
together  in  each  room  another  would  be  left  to  work  alone, 
as  she  must  later  in  occasional  room  inspections.  In  fact, 
we  can  be  sure  of  over  20  rooms  inspected  a  day  from 
the  small  force  of  five  above  mentioned,  which  for  the  total 
of  probably  150  rooms  in  the  city,  would  make  about  eight 
days.  So  two  weeks  would  probably  be  ample  with  such 
a  system. 

Some  doctors  lay  claim  to  250  pupils  room-inspected  an 
hour,  but  these  are  only  very  partial  inspections,  for  signs 
of  parasitic  or  infectious  disorders.  This  first  general  rou- 
tine inspection  would  make  a  fair  substitute  for  an  exam- 
ination, especially  if  there  were  any  careful  attention  given 
to  vision  and  hearing.  It  is  a  general  inspection  of  the 
child  for  any  serious  defects,  ailments  or  conditions  which 
should  receive  early  treatment  and  care.  No  vision  or 
hearing  tests,  as  such,  are  made,  but  all  obvious  cases,  like 
strabismus  (cross-eye),  or  inflamed  eyes  from  eye-strain, 
may  be  recorded  and  referred  with  instructions. 

The  principal  ailments  found  will  probably  be  minor 
skin  ailments  of  a  filthy  or  infectious  character,  although 
most  ailments  will  be  represented.  If  there  have  been 
nurse-inspections  during  the  summer,  fewer  cases  will  be 
found,  but  there  are  always  sufficient  numbers  to  warrant 
rigorous  measures  for  nipping  their  spread  in  the  bud. 

THE    METHOD    OF    CLASSROOM    INSPECTIONS 

The  central  instrument  in  all  medical  supervision  (in- 
spection) is  the  individual,  cumulative  health  record  card 
of  each  pupil.  On  it  is  recorded  the  health  history  of  the 
child  during  his  school  years,  and  in  some  cases  for  the 
years  previous  to  his  entering  school.  The  development 
of  the  science  of  educational  hygiene  and  the  practical  con- 


MEDICAL  INSPECTION  PLAN  309 

trol  of  health  matters  must  depend  very  much  upon  the 
quality  of  such  individual  health  histories.  Scientific  con- 
trol of  living  conditions  of  children,  or  of  any  other  phe- 
nomena, rests  upon  the  basis  of  accurate  and  carefully  se- 
lected facts.  With  this  principle  in  mind,  and  the  prog- 
ress of  child  and  of  educational  hygiene  as  a  much-to-be- 
desired  practical  necessity,  by  what  standards  shall  we  judge 
such  health  record  cards?  Tentative  standards  used  by  the 
author  are  as  follows: 

a.  The  record  must  be  a  separate  filing  card,  not  a  page 

in  a  book,  nor  a  loose  sheet  of  paper.  The  great- 
est device,  or  instrument,  for  inductive  thinking  yet 
invented  is  the  well-devised  card-index  system.  Pro- 
fessor Giddings  well  says  that  Jevons'  invention,  of 
a  "deductive  logic  machine,"  is  but  a  useless  toy  com- 
pared with  the  modern  "inductive  logic  machine," 
the  card  index. 

b.  This   card  must  go  with  the   child   from   room  to 
room,  from  school  to  school,  and  from  city  to  city 
throughout  his  school  life.    The  cities  that  are  using 
cards  good  for  one  year  only  are  wasting  money  and 
not   getting   the   cumulative    history  which    can   al- 
ways be  before  teacher,  nurse  and  physician  when 
they  study  the  child  from  the  standpoint  of  his  health. 

c.  The  record  must,  as  nearly  as  possible,  contain  each 

child's  entire  health  history,  especially  of  serious  dis- 
eases, injuries,  or  defects,  winter  or  summer,  and  the 
results  of  treatments,  and  dates  of  cures. 

d.  The  records  must  be  made  by  both  physicians  and 
nurses,  and  their  records  distinguished,  say  black  ink 
for  the  physician  and  red  for  nurse.    With  our  plan 
most  of  the  records  will  be  in  red  ink.     Examina- 
tions by  specialists,  dentists,  aurists,  or  oculists  can 
also  be  recorded  on  the  same  card. 

e.  Arrangement  must  be  made  for  recording  the  chang- 

ing addresses,  rooms,  and  schools  of  pupils.  The 
telephone  number  of  the  parents  is  desirable  wher- 
ever it  can  be  obtained. 


310    SCHOOL  HEALTH  ADMINISTRATION 

f.  The  results  of  both  examinations  and  inspections  are 

to  be  recorded. 

g.  The  card  must  either  have  the  diseases  and  defects 

most  often  found  and  most  to  be  emphasized  printed 
thereon,  or  be  used  in  constant  connection  with  a  de- 
tailed and  numbered  list  of  such  ailments  (code),  for 
which  only  the  code  numbers  need  be  used,  or  the 
code  number  accompanied  by  an  abbreviation  for  a 
special  and  unusual  ailment.  The  Cleveland  card, 
most  carefully  drawn  up,  has  a  code  entirely  too  brief 
printed  upon  it,  and  has  no  satisfactory  arrangement 
for  recording  treatments  and  cures.  The  New  York 
city  and  the  cards  devised  by  Burks,  Hoag,  and  Cor- 
nell have  similar  or  other  serious  defects. 

h.  The  card  must  leave  space  with  each  year's  record 
for  writing  in  any  general  recommendations,  sugges- 
tions to  teachers,  and  the  like,  which  are  so  individ- 
ual that  they  cannot  be  reduced  to  code  numbers  or 
other  signs.  Real  health  records  have  been  prac- 
tically prevented  by  attempting  to  reduce  the  whole 
matter  to  making  checks  opposite  a  few  ailments. 

i.  The  signs,  or  symbols,  used  to  save  space  and  time 
and  for  a  degree  of  privacy,  if  desired,  should  very 
probably  be  printed  on  each  card.  The  need  of  keep- 
ing the  children  in  entire  ignorance  of  their  ailments 
does  not  appeal  to  the  author's  experience.  Democ- 
racy is  better.  Some  of  these  signs,  to  be  found  on 
the  card  offered  herewith  and  devised  for  tentative 
testing  by  the  author,  may  well  be : — 

X — A  cross,  for  "needs  treatment,  and  should  be  re- 
ferred to  parents." 

O — a  circle  around  this  cross,  to  be  made  by  the  nurse 
when  the  ailment  is  cured. 

O — a  circle  in  the  second  space,  to  the  right  of  the  X, 
showing  that  the  ailment  has  not  been  cured,  but 
has  been  Improved.  No  circles  will  show  that  the 
case  has  not  been  cured,  or  improved,  or  the  child 
has  moved  away,  without  his  card,  or  the  family 


CC 
ui 
I 


ts 


H* 


312    SCHOOL  HEALTH  ADMINISTRATION 

has  refused  treatment,  or  the  family  physician  has 
called  the  case  "negative,"  that  is,  too  minor  an  ail- 
ment for  treatment  or  operation.  A  diagonal  line 
may  be  drawn  through  admitted  negative  cases  and 
deducted  from  the  number  previously  reported. 

| — a  vertical  line,  to  the  right  of  the  X  or  O,  showing 
in  red  that  the  nurse,  janitress,  or  school  clinic  has 
treated  the  case,  and  in  black  that  some  other  "out- 
side" agency  has  made  a  treatment  or  series  of 
treatments.  Red  lines  over  near  the  space  for  re- 
marks on  the  same  horizontal  line,  or  to  the  left  of 
this  space  if  desired,  may  be  used  to  indicate  times 
the  nurse  has  taken  the  child  to  dispensary,  family 
physician,  or  clinic.  Home  hygiene  visits,  or  sim- 
ply home  visits,  may  be  similarly  recorded  under 
that  heading. 

P — in  the  space  for  the  date  of  the  annual  medical  ex- 
amination at  the  top  will  mean  that  the  parent  or 
guardian  of  the  child  has  been  present  at  that  ex- 
amination. This  is  important,  for  better  results  fre- 
quently follow  if  parents  are  present,  and  the  records 
should  show  it.  In  general,  however,  parents  attend 
much  better  with  their  children  school  clinics. 

V — a  check,  in  place  of  an  X,  will  show  that  the  ailment 
is  too  minor  to  be  referred  for  treatment.  Few  such 
checks  will  be  required.  Certain  incipient  ailments 
must,  perhaps,  be  noticed  in  this  way,  however.  The 
discretion  is  with  the  supervisor  or  other  officers. 
Too  many  very  minor  cases  are  now  being  recorded 
in  many  cities.  Be  conservative.  Check  cases  need 
not  be  reported. 

E — will  show  that  the  child  has  been  excluded  for  the 
ailment  marked  X. 

R — will  show  that  the  child  has  been  readmitted.  The 
teachers  will  keep  a  record  of  the  time  lost  by  all 
exclusion  or  illness  absence  and  record  it  at  the  bot- 
tom for  each  term  each  year. 

Other  signs  can  be  devised  for  other  meanings. 


MEDICAL  INSPECTION  PLAN  313 

In  the  space  for  remarks,  the  medical  officials  will  write 
such  facts  or  suggestions  as  cannot  be  given  by  the  system 
of  signs. 

The  back  of  card  number  one  is  not  here  reproduced. 
Four  horizontal  spaces  at  the  top  may  be  left  for:  the  pupil's 
name  and  addresses,  the  history  of  measles,  scarlet  fever, 
diphtheria,  whooping  cough,  chicken  pox,  vaccination  and 
other  ailments  with  spaces  for  checking  or  writing  in  the 
dates,  the  nationality  if  desired,  and  spaces  for  changing 
room  numbers  or  letters.  The  fourth  space  may  be  used  for 
the  symbols  given  on  the  face,  and  for  others  desired.  Below 
the  headings,  the  card  may  be  made  up  the  same  as  on  the 
face,  for  three  years. 

To  the  right  of  these,  I  have  a  section  for  Home 
Hygiene  Inspection,  printed  in  the  space  for  dates  of  ex- 
aminations and  presence  of  parents,  somewhat  similar  to 
the  Cleveland  and  the  Hoag  cards  (see  Health  Index  of 
Children).  Beneath  this  heading  on  the  25  lines  I  have 
printed  (with  five  vertical  spaces  to  the  right)  the  follow- 
ing: Grade,  Date,  Children  in  school — Boys,  Girls,  Num- 
ber of  rooms,  Number  of  bed-rooms,  Number  of  beds, 
Bath  tub?,  Ventilation,  G — F — B  (good,  fair,  or  bad), 
Lighting,  G — F — B,  Cleanliness,  G — F — B,  Number  of 
families  using  closet,  Financ.  (for  financial  condition), 
G — F — B,  Nourishment,  G — F — B,  Children's  hours  of 
sleep,  Home  study  opportunity,  Mother,  Father,  Sisters, 
Brothers,  Boarders,  Co-operation  with  the  school  (i.  e., 
how  well  they  respond  to  the  nurse's  and  teachers'  efforts) 
and  spaces  for  writing  in  other  data.  This  matter  is,  of 
course,  unnecessary  on  card  number  two. 

FURTHER  SUGGESTIONS   FOR  USING  THE  RECORD  CARD 

It  is  relatively  unsatisfactory  to  attempt  to  place  under 
even  twenty-four  headings  the  ailments  which  physician  and 
nurse  must  look  for  and  record.  One  line  may  be  over- 
crowded while  there  are  left  many  lines  unused,  and  ailments 
not  printed  thereon  may  be  found.  To  overcome  this  diffi- 
culty, a  space  over  a  half-inch  wide  has  been  left  for  writ- 
ing in  the  name,  abbreviation,  or  code  number  found  in  the 


314    SCHOOL  HEALTH  ADMINISTRATION 

weekly  report  for  fifty-four  ailments  and  groups  of  ailments, 
the  term  "ailment"  referring  to  all  the  health  disorders  of 
childhood,  including  physical  defects. 

Still  further  to  overcome  this  difficulty,  all  names  of  ail- 
ments may  well  be  left  off  the  card,  the  spaces  mentioned 
widened  for  each  year  entirely  to  take  up  the  space  where 
names  for  ailments  are  printed,  and  only  code  numbers  used 
in  the  first  narrow  column  for  ailments  each  year.  The  fig- 
ure (code  number)  there  would  indicate  that  the  ailment 
had  been  found,  and  the  signs  above  mentioned  would  fol- 
low as  before,  on  the  same  horizontal  line.  Or  the  card 
may  be  entirely  reorganized  on  a  freer  basis,  giving  one  like 
the  second  type  here  reproduced. 

CARD  NUMBER  TWO 

The  principal  disadvantages  of  the  first  card  are  ( i ) 
that  it  is  impossible  to  write  on  it  the  entire  series  of  efforts 
which  may  be  necessary  to  get  cured  one  case,  resulting 
in  the  overcrowding  of  one  line  or  two  and  leaving  blank 
a  large  part  of  the  card  opposite  ailments  from  which  the 
child  does  not  suffer,  (2)  that  since  the  names  of  ailments 
must  be  general  and  in  only  24  divisions,  the  code  num- 
bers and  the  abbreviations  or  full  names  of  the  specific 
ailments  must  be  written  out  anyway.  Even  with  a  card 
long  enough  vertically  to  make  possible  the  printing  of  the 
54  classes  of  ailments,  it  would  still  be  necessary  to  write 
in  the  specific  name  (say,  for  minor  skin  diseases).  An- 
other weakness  is  the  home  hygiene  inspection  division 
separated  from  the  ailment  and  time  of  inspection  or  fol- 
lowing up  of  the  case.  Yet  this  card  has  been  declared, 
by  a  committee  studying  the  record  systems  of  over  seventy 
cities,  superior  to  all  in  use.  Burks'  interesting  card  or 
slip  (Health  and  the  School,  page  179)  has  the  same  and 
other  defects,  his  system  being  devised  more  for  such  large 
cities  as  Philadelphia,  with  large  central  office  forces. 

Our  card  number  two  of  which  the  face,  partially  filled 
in,  is  given,  has  been  evolved  out  of  all  these  defects  and 
difficulties.  It  gives  freedom  to  record  essential  data  not 
easily  placed  in  a  system  of  rigid  symbols,  economizes 


( 


10 


5-  £  * 


04. 


316    SCHOOL  HEALTH  ADMINISTRATION 

space,  shows  immediately  what  ailments  have  been  found 
and  what  has  been  done  with  them,  records  both  inspec- 
tions and  examinations  and  all  dates,  and  makes  possible 
adequate  reporting  of  follow-up  and  home  hygiene  work. 
Most  of  it  will  be  filled  in  (with  red  ink)  by  the  nurses. 
Another  space  may  be  used  for  printing  in  other  symbols 
while  the  number  of  lines  for  the  second  year  may  be  de- 
creased to  four.  The  card  may  be  arranged  for  ten  or 
more  years  of  school  life,  five  or  six  years  on  each  side. 
The  heading  for  the  back  of  card  i  should  also  be  used 
for  this  card.  No  home  hygiene  space  need  be  arranged 
as  this  has  been  provided  for  each  year.  For  special  cases, 
the  five  lines  for  the  first  year  may  be  used  for  a  careful 
health  history. 

The  card  will,  of  course,  be  used  with  the  classification 
and  nomenclature  of  ailments  in  view  as  they  are  printed 
on  the  weekly  report. 

Interpreted,  some  of  the  written-in  record  has  the 
following  meaning:  For  the  first  year,  1910-11,  enlarged 
tonsils  and  adenoids  were  found  at  the  time  of  the  first 
(September)  routine  inspection  of  all  children.  We  see  at 
once  that  they  were  found  and  cured.  They  were  referred 
September  the  tenth,  but  the  family  did  not  respond  well; 
so  the  mother,  a  poor  widow,  was  visited  on  the  fifteenth. 
The  latter  gave  the  nurse  permission  to  take  the  child  to 
the  dispensary  where  her  adenoids  and  tonsils  were  removed 
on  the  twenty-second.  The  nurse  should  have  seen  the 
child  every  day  or  two  immediately  after  the  operation, 
but  probably  wisely  depended  upon  a  responsible  teacher 
to  send  her  for  inspection  if  her  wounds  did  not  heal  well. 
On  the  second  of  October,  however,  she  did  inspect  the 
child,  then  seven  years  of  age,  and  found  her  apparently 
cured.  She  could  not  then  state  whether  the  adenoids  would 
grow  again'  but  apparently  the  child  was  developing  satis- 
factory nasal  breathing,  in  place  of  the  former  mouth 
breathing. 

For  some  reason,  the  child  was  given  her  annual  exam- 
ination on  September  the  fourteenth,  which  resulted  in 


MEDICAL  INSPECTION  PLAN  317 

the  finding  of  pediculosis  and  nits,  but  her  vision  was  good 
with  her  glasses  on,  and  her  hearing  was  satisfactory.  The 
subject  of  pediculosis  was  brought  up  at  the  first  home 
visit  recorded  above  and  the  mother  promised  treatment 
which  she  carried  out,  with  improved  condition,  and  twice 
afterward  following  notice  by  the  nurse.  The  examination 
showed  the  ailment;  it  was  improved;  two  inspections 
showed  the  ailment  later,  and  it  was  again  improved.  The 
teacher  had  evidently  sent  the  child  to  the  nurse  for  the 
inspections  or  the  nurse  had  kept  after  the  case  and  called 
the  child  out  those  two  times. 

The  next  year,  1911-12,  the  child  was  again  mouth- 
breathing  and  the  adenoids  had  probably  grown  again  but 
the  nurse  took  the  child  to  the  dispensary  and  an  operation 
was  spared  by  the  dilation  of  the  child's  nostrils.  This 
should  have  been  done,  and  perhaps  continued  by  the  nurse, 
during  the  first  year.  The  other  items  are  probably  easily 
read.  V  equals  home  visit;  T  equals  teeth;  Tr  equals 
treated  or  treatment;  H  equals  board  of  health.  Any 
added  symbols  should  be  uniform  for  each  city,  at  least. 

Where  a  child  presents  unusual  need  for  treatments,  the 
spaces  for  two  or  more  years  may  be  used  for  recording 
them.  A  five  by  eight  card  should  be  standard  since  the 
smaller  ones  unnecessarily  cramp  the  work.  Our  card  num- 
ber two  has  been  reduced  for  book  purposes  to  a  seven-inch 
length.  We  have  not  shown  a  record  of  days  lost  by  illness 
nor  a  very  wide  range  of  home  hygiene  reporting,  although 
the  form  admits  of  it. 

Either  of  these  cards,  printed  on  both  sides,  and  contain- 
ing the  names  of  the  places  using  them,  and  the  other  forms 
given  later,  will  be  sold  in  quantities  by  the  publishing  de- 
partment of  Teachers  College,  Columbia  University,  New 
York.  The  appearance  of  the  cards  will  be  improved  by 
printing  in  all  words. 

Where  a  child  spends  more  than  eight  years  in  the 
elementary  school  system  or  enters  the  high  school,  another 
card  may  be  clipped  to  the  original  card.  In  fact,  for  very 
serious  and  prolonged  cases,  the  annual  spaces  with  dates 


3i8     SCHOOL  HEALTH  ADMINISTRATION 

above  may  be  turned  into  term  spaces  and  an  additional 
card  added  earlier  than  the  ninth  year  of  school  life. 
Whether  cards  should  begin  with  the  kindergarten  chil- 
dren, may  rest  with  the  medical  director,  and  superintendent 
of  schools.  They  probably  should-  with  the  exception  of 
the  vision  test  perhaps.  Provision  for  changing  addresses 
may  be  made  by  furnishing  gummed  strips  of  paper  the  size 
of  the  address  space.  This  is  a  compromise  plan  to  save 
space.  On  the  second  card  the  addresses  may  be  written 
in  the  first  space  to  the  right  of  the  symbol  spaces  for  each 
year  after  the  spaces  at  the  top  have  been  used. 

Thus  we  have  offered  two  record  cards  instead  of  one 
for  use,  adaptation,  and  criticism.  The  first  has  many  ad- 
vantages, but  limits  seriously  the  amount  of  space  for  re- 
cording the  facts  regarding  any  one  ailment;  the  second  is 
simpler,  and  gives  plenty  of  space  for  recording  the  nature 
and  treatment  of  any  ailment.  It  also  affords  more  chances 
for  error  in  using  and  interpreting  the  code  numbers,  per- 
haps. The  second  will  probably  win  out  after  trial. 

These  cards  (5  by  8  inches  in  size)  may  be  kept  in 
the  teachers'  classrooms  in  small,  durable  filing  cases,  such 
as  are  furnished  in  New  Bedford,  Mass.  It  is  probably 
not  wise  to  keep  all  the  cards  together  in  the  medical  in- 
spection room,  for  several  reasons.  At  each  inspection  or 
examination  the  child  takes  his  card  in  a  clean  piece  of 
paper,  or  one  child  carries  several  of  the  cards,  or  some 
other  person,  nurse,  janitress  or  principal's  clerk,  collects 
them,  and  takes  them  to  the  health  officers'  room.  For 
room  inspections,  of  course,  the  cards  need  not  be  taken  out 
of  the  rooms,  except  as  the  nurse  uses  them  for  making 
her  records  and  reports.  If  the  health  histories  are  to  be 
used  and  if  teachers  are  to  be  educated  in  health  watchful- 
ness, the  cards  must  be  kept  before  them  in  their  rooms. 

The  "parasitic  ailments"  are  favus,  ringworm  of  body 
or  scalp,  pediculosis  or  vermin,  scabies,  and  one  or  two 
others  seldom  if  ever  found.  Where  a  child  has  two  such 
ailments,  use  the  space  for  infectious  ailments  or  for  skin 
ailments  in  the  section  above,  writing  in  the  name  or  code 


MEDICAL  INSPECTION  PLAN  319 

number  on  the  right.  (No  such  trouble  will  arise  with  the 
second  card  presented.)  Physical  defects  are  placed  at  the 
top  as  in  the  weekly  reports  and  the  tentative  standard 
classification  of  ailments. 

THE    METHOD   OF    THE    SEPTEMBER    ROOM-INSPECTION 

Coming  back  to  the  September  room-inspection  with  an 
understanding  of  the  individual  health  record  cards,  let  us 
briefly  suggest  a  workable  method.  .  In  one  of  the  first 
plans  of  this  kind  drafted  by  the  author  in  1908,  the 
doctor  and  nurse  were  to  go  to  separate  rooms  and  the 
teachers  were  to  make  the  records  on  the  cards  for  them. 
If  teachers  could  do  this  well  or  if  it  were  thought  valuable 
enough  training  to  take  the  time  to  teach  them,  this  would 
be  satisfactory;  since  the  general  room-inspection  at  any 
time  could  be  done  about  twice  as  rapidly  as  when  the 
nurse  and  physician  work  together.  Teachers,  of  course, 
need  such  training  and  knowledge  of  both  the  cards  and 
the  children. 

However,  the  nurse  frequently  needs  the  doctor's  sup- 
posedly better  knowledge  and  advice,   and  she  can  record 
the  matter  on  the  cards  very  much  better  than  teachers. 
Doctors  who  have  tried  both  methods  say  that  the  rapidity 
and  ease  with  which  the  nurse  and  doctor  working  as  a 
team  can  do  room-inspection  eliminate  all  other  methods. 
The  nurse,   however,   cannot  see   each   case  so  well  when 
she  is  sitting  at  a  desk  busily  copying  signs;  and  most  values 
might  be  gained  by  having  the  teacher  make  the  records 
with   the   nurse   free   to   watch   both   her   and   the   doctor. 
This    probably    deserves    test.     It    serves    to    educate  the 
teacher,  but  leaves  the  class-room  of  children  to  some  ex- 
tent, undirected,  although  a  strong  teacher  can  use  the  situa- 
tion as  she  thinks  best,   either  for  continued  study  by  the 
pupils  or  for  watching  the  work  proceed,  and  getting  an 
intelligent  attitude  toward  health  matters.     This  is  again  a 
matter  to  be  tested.    The  outcome  will  probably  be  that  the 
nurse  will  record  and  learn  to  see  the  cases  too. 

Near  the  back  of  the   room  on  the  left  side   of  the 


320    SCHOOL  HEALTH  ADMINISTRATION 

pupils  will  probably  be  found  good  light.  Here  the  doctor 
can  take  his  stand  and  the  pupils  by  rows  of  five  or  six,  or 
boys  first  and  then  girls,  or  in  any  other  convenient  way, 
can  file  pass  him.  He  may  be  seated,  since  it  is  well,  with 
certain  exceptions,  to  start  with  the  pupils  in  the  lowest 
grades  in  both  general  inspection  and  in  examinations. 

The  nurse,  let  us  say,  sits  at  a  desk  nearby  and  records 
the  doctor's  findings  and  the  disposition  of  each  case.  The 
physician  gives  a  quick,  accurate  glance  at  hair,  scalp,  ears, 
eyes  and  eyelids,  face,  nose,  mouth,  teeth,  tonsils  and  throat, 
hands  and  skin,  and  quickly  sizes  up  the  general  condi- 
tion of  the  pupil.  The  doctor  does  not  touch  the  pupil 
but  has  each  child  open  the  mouth,  show  the  hands,  pull 
down  the  eyelids,  perhaps,  and,  in  the  case  of  girls,  lift 
up  the  back  hair.  Wooden  tongue  depressors  are  used  for 
the  mouth  examination,  and  no  depressor  is  to  be  used  more 
than  once.  Where  plant  tag-sticks  are  used  for  depressors 
each  one  may  be  broken  in  two  and  used  for  two  pupils. 
With  increasing  skill,  all  the  pupils  of  a  room  can  be  in- 
spected in  a  very  short  time,  less  than  a  half  hour,  and  aver- 
aging, perhaps,  two  pupils  to  a  minute. 

The  standard  for  the  selection  of  cases  for  record  can 
be  seen  in  the  following  question  which  the  doctor  must 
ask  himself:     May  this  child  remain  in  the  school  without 
injury  to  himself  or  to  others,  and  is  this  ailment  one  which 
should  have  immediate  care  and  treatment,  and  one  about 
which  the  parent  should  be  informed?    If,  in  his  judgment, 
and  probably  with  the  advice  of  the  nurse,   he  concludes 
that  it  is  a  sufficiently  urgent  case  of  any  kind,  he  gives  the 
nurse  the  code  number  of  the  ailment  from  the  printed  code 
before  him,  and  indicates  what  shall  be  done  with  the  case. 
If  he  is  in  some  doubt,  the  child  is  asked  to  take  his  seat 
or  pass  elsewhere  until  after  the  other  pupils  are  inspected, 
and  may  then  be  taken  into  the  hall  or  health  room  for 
further  inspection.    In  Newark,  N.  J.,  at  most  room-inspec- 
tions the  pupils  go  singly  into  the  hall  where  they  are  in- 
spected by  the  doctor,  the  nurse,  or  the  two  together.    This 
plan  has  its  advantages. 


MEDICAL  INSPECTION  PLAN  321 

The  doctor  should  be  conservative  and  practical  in  his 
judgments.  Most  minor  uninfectious  cases  may  wait  for 
the  routine  examination  when  the  parent  may  be  present. 
Further  standardization  can  come  with  experience,  super- 
vision and  standardization  clinics. 

EXCLUSIONS 

Doctors  and  nurses  must  also  be  very  careful  and  con- 
servative about  the  exclusion  of  pupils  from  school.  On 
the  average,  such  exclusions  last,  for  all  ailments,  nearly 
two  or  three  weeks.  Some  are  unnecessarily  excluded  for 
months.  Most  of  the  parasitic  ailment  cases  may  remain 
in  school  with  adequate  treatment  and  control.  Where  an 
epidemic  of  infectious  disease  is  imminent  less  suspicious 
cases  may  be  excluded  and  throat  cultures  taken,  but  con- 
servative judgment  is  not  even  here  amiss.  The  nurse 
should  take  cultures  in  every  case  of  sore  throat.  These 
cultures  must  be  tested  and  the  children  readmitted  if  nega- 
tive (i.  e.,  if  the  Klebs-Loeffler  baccilli  are  not  found)  as 
soon  as  possible. 

Children  requiring  exclusion  may  be  given  an  exclusion 
slip  at  the  end  of  the  inspection  of  that  room,  or  imme- 
diately, if  desired.  The  principal  of  the  school  may  have 
such  children  referred  to  him,  and  may  mail  or  send  the 
slip  to  the  parents  from  his  office,  besides  sending  an  oral 
message  by  the  children.  Or,  the  telephone  may  be  used. 
The  teacher  should  be  notified  of  the  exclusion  and  of  the 
date  fixed  for  the  child's  return  to  school.  This  may  be 
written  on  the  card  protector. 

Exclusions  may  be  made  for  the  following  infectious 
ailments :  diptheria,  or  sore  throat  or  tonsilitis  possibly 
pointing  to  infection,  scarlet  fever,  whooping-cough,  chicken 
pox,  measles,  mumps,  trachoma,  or  any  other  possibly  acute 
infectious  disease,  and  such  parasitic  and  minor  infectious 
ailments  as  may  be  adequately  treated  over  night  if  strongly 
called  to  the  parents'  attention.  Montclair  and  some  other 
cities  have  such  cases  treated  in  the  school  by  the  nurse  or 
janitress,  thus  saving  very  much  absence.  Parents  are  tried 


322    SCHOOL  HEALTH  ADMINISTRATION 


first,  and  then,  if  the  home  does  not  adequately  eradicate  the 
ailment,  permission  is  gained  for  the  school  treatment. 
Legal  compulsion  may  be  required,  and  should  be  used  with- 
out fear  or  favor  for  the  "filth"  disorders. 

The  nurse  may  make  out  the  exclusion  slip  which  should 
be  simple,  dignified  and  adequately  instructive.  If  the  back 
can  be  used  for  health  advice,  the  chance  should  not  be 
missed.  The  seal  of  the  city  printed  on  each  as  is  done  in 
the  state  forms  of  Massachusetts  and  certain  cities,  will  ap- 
peal in  the  right  way  to  many  parents.  The  following 
exclusion  form  has  several  advantages  in  the  way  of 
economy : 

^  EXCLUSION    RECORD         MEDICAL   SUPERVISION   OF 

SCHOOLS 


No. 


Date. 


191 


School. .  Room 


Pupil 

Address    

Cause  of  Exclusion: 


Readmitted, 


School  days  lost, 


191.. 


Montclair, 
Date.. 


New    Jersey. 


191 


School Room, Grade, 

Pupil's  name , 


Home  address 

The  above  named  pupil  is  hereby  or- 
dered to  discontinue  attendance  at 
school  temporarily  for  the  following 


reasons: 


School  Nurse,  M.D. 
(Hand  to  pupil  excluded.) 

over. 


This  entire  form  need  not  be  more  than  six  inches  long 
and  two  and  a  half  inches  wide. 

On  the  back  of  the  long  part,  not  the  stub,  should  be 
printed  these  and  any  other  directions,  general  advice,  or 
short  article  from  city  or  state  laws : 

The  ailment  mentioned  on  the  other  side  of  this  notice  is 
infectious  (contagious),  and  liable  to  be  transmitted,  or  "given," 


MEDICAL  INSPECTION  PLAN  323 

to  other  children.     The  child  should  receive  prompt  treatment 
by  a  physician  or  the  school  nurse,  and  should  return  to  school 

,  191 ..,  for  inspection  by  the 

school  physician  or  nurse.     If  found  free  from  infection  he  may 
then  resume  attendance  at  school. 

Every  reasonable  effort  should  be  made  to  give  each  child 
the  full  benefit  of  every  possible  day  of  school  attendance. 

A  DUPLICATE   BOOK   FOR  DOCTOR  AND  NURSE 

This  form,  separable  from  its  stub,  should  be  printed  as 
is  a  check  book,  and,  whenever  desirable,  as  in  the  case 
of  acute  infectious  diseases,  will,  with  small  sheets  of  copy- 
ing carbon,  give  four  forms,  the  original  for  the  parent, 
the  stub  for  the  hygiene  department,  the  carbon  copy  for 
the  board  of  health  as  their  notification,  and  the  carbon 
stub  for  the  nurse's  or  doctor's  record.  The  notice  can  be 
sent  home  in  several  different  ways,  depending  upon  cir- 
cumstances. One  of  these  exclusion  books  should  be  kept 
in  each  school,  and  for  its  pupils  only. 

To  avoid  conflict  of  jurisdiction,  the  city  health  officer 
and  the  director  of  hygiene,  or  superintendent,  should  meet 
and  agree  upon  a  plan  of  co-operation  for  readmitting 
pupils  after  exclusion  or  illness  absence.  The  following  is 
the  result  of  such  a  meeting  at  Meriden,  Connecticut,  in 
the  year  studied  and  about  a  month  after  the  work  of 
medical  supervision  had  begun : 

"It  was  agreed  that  the  city  health  officer  should  write 
permits  for  returning  to  school  after  exclusion  for  small- 
pox, scarlet  fever,  diptheria  and  membranous  croup,  and  that 
the  school  physician  only  should  write  certificates  for  re- 
turning to  school  after  measles,  whooping  cough,  consump- 
tion, chickenpox,  mumps,  sore  throat,  lice,  scabies  (itch), 
and  other  skin  diseases,  and  other  minor  ailments." 

And  it  was  furthermore  agreed  that  the  school  phy- 
sicians should  give  no  readmission  for  diseases  assigned  to 
the  health  department  and  the  latter  agreed  to  sign  no 
permits  to  return  for  diseases  assigned  to  the  school 
physicians.  Practically,  then,  the  school  medical  service 


324    SCHOOL  HEALTH  ADMINISTRATION 

readmitted  pupils  for  everything  except  scarlet  fever  and 
diphtheria,  since  small-pox  is  seldom  if  ever  found. 

Notice  of  cases  of  acute  infectious  diseases  like  diph- 
theria, scarlet  fever,  measles,  German  measles,  perhaps, 
small-pox,  if  ever  found,  and  chicken-pox  should  be  imme- 
diately telephoned  to  the  city  health  department,  the  ex- 
clusion notice  being  sent  later,  if  necessary. 

The  board  of  health  will,  of  course,  notify  the  schools 
each  day  of  all  children  ill  with  infectious  diseases,  quar- 
antined or  not,  and  also  when  these  pupils  may  be  read- 
mitted. Such  ailments  whether  found  in  the  schools  or 
not  should  be  recorded  on  the  record  card  and  in  the 
reports. 

Conjunctivitis,  impetigo,  trachoma  and  the  parasitic  ail- 
ments will  be  handled  by  the  nurse.  For  trachoma,  she  will 
find  it  best  to  give  instruction  rather  than  treatment. 

Rare  cases  of  tuberculosis  should  be  reported  to  the 
superintendent  or  director  of  hygiene  for  special  considera- 
tion. When  diphtheria  develops  it  is  well  to  culture  the 
throats  of  all  children  in  the  class  to  discover  possible 
carriers. 

THE   SPIRIT  OF  THE  INSPECTIONS 

Let  us  remember  that  we  are  still  in  a  primary  room  of 
a  school  in  our  typical  city  at  the  work  of  the  September 
class-room  inspection.  A  great  deal  will  depend  upon  the 
spirit  in  which  such  work  is  carried  on.  Physicians  are  fre- 
quently very  unpedagogical  in  their  treatment  of  the  chil- 
dren; and  some  of  the  cases  of  such  unpedagogical  treat- 
ment, witnessed  by  the  author  in  dispensaries  and  at  school 
inspections  and  examinations,  would  appropriately  bear  the 
title  of  "Crimes  Against  Childhood."  Individuals,  male  or 
female,  found  unadapted  for  this  personal,  humane  work 
with  children  should  be  relieved  of  it  as  soon  as  they  can  be 
discovered.  The  atmosphere  of  school  medical  work  should 
be  that  of  health,  happiness,  and  co-operation,  not  that  of 
so  many  of  our  public  dispensaries. 


MEDICAL  INSPECTION  PLAN  325 

REPORTING    THE    ROOM-INSPECTION 

When  the  class  has  been  room-inspected,  to  coin  a  word, 
the  nurse  will  take  all  the  cards  of  ailing  pupils  to  the 
principal's  office  or  the  health  room,  where  they  can  be 
reported  after  the  morning's  work  with  the  physician.  In 
her  case  book  for  each  school  she  will  write  down  the 
name,  address,  room  and  ailment  of  each  defective  and  ail- 
ing child  and  the  date.  When  she  sends  notices  home  with 
the  children  who  are  ailing  but  not  excluded  and  gets  no 
satisfactory  results  in  treatment  within  three  days  or  a 
week,  the  time  for  a  second  notice,  or  for  home  visiting  has 
come,  which  may  even  end  with  the  doctor's  visit  or  that 
of  an  officer  of  the  law.  After  the  list  of  cases  has  been 
placed  in  her  book,  the  cards  can  be  returned  to  the  room, 
where  the  teacher  will  give  them  a  separate  place  in  her 
file,  or  mark  them  with  colored  clips.  At  the  end  of  the  day, 
the  nurse  will  record  all  the  work  of  inspection  and  the 
findings  in  the  column  for  that  day's  work,  on  the  weekly 
report  form.  This  daily  and  weekly  report  will  be  treated 
under  "examinations." 
b.  Occasional  Room-Inspections 

Occasionally,  other  room-inspections  (special  room-in- 
spection is  a  good  term)  must  be  made  by  the  nurse  after 
the  routine  one  in  September.  Very  rarely  will  the  doctor 
be  needed  for  such  work.  The  ailments  found,  she  can  her- 
self record;  or,  where  there  are  very  many  cases,  she  may 
find  the  co-operation  of  the  teacher  very  helpful.  The 
method  can  be  that  of  the  general  inspection  described,  or 
she  can  simply  pass  along  the  aisles  and  inspect  the  chil- 
dren. The  latter  can  have  their  hands  on  the  desks,  and 
the  nurse,  passing  along  from  the  rear,  can  easily  note  the 
condition  of  the  hair  and  scalp,  as  well  as  other  features. 
The  nurses  of  Newark  made  an  average  of  nearly  500 
occasional  class-room  inspections  each  during  the  school  year 
studied,  besides  about  21,000  individual  inspections  and 
over  a  thousand  home  visits  each.  These  room-inspections 
are  especially  valuable  in  poor,  or  foreign  districts  in  bring- 


326    SCHOOL  HEALTH  ADMINISTRATION 

ing  up  the  health  and  cleanliness  standards  towards  that  of 
civilized  America.     They  are  also  valuable,  as  suggested, 
in  the  case  of  an  impending  epidemic. 
c.  Individual  Inspections 

Individual  inspections  are  to  be  made  principally  by  the 
nurse,  but  also,  if  necessary,  by  the  physician  in  the  one  build- 
ing he  visits  for  two  or  more  hours  each  day.  Only  urgent 
cases  are  to  be  referred  either  by  nurse  or  teacher  to  the 
doctor.  The  principal  classes  of  individual  inspections  are 
as  follows: 
w.  Pupils  referred  at  the  time  of  the  nurse's  visit,  by  the 

teachers. 

x.  Pupils  entering  that  school  for  the  first  time,  any  age. 
y.  Pupils  who  have  been  out  of  school  for  any  reason  more 
than  three  days,  especially    excluded,    or    quarantined 
cases. 
z.  Pupils  brought  to  the  attention  of  the  nurse  in  the  homes. 

Where  principals  are,  or  become,  qualified,  a  large  num- 
ber of  the  readmittance  inspections  may  be  left  to  them. 
The  importance  of  the  health  training  of  principals  and 
teachers  and  the  books  they  can  use  in  study,  will  be  brought 
out  later.  A  principal  who  hasn't  such  a  knowledge  of 
children  (child-study)  needs  to  "study  up."  He  must,  how- 
ever, beware  of  cocksureness  after  little  study. 

The  usual  place  for  the  individual  inspections  is  at  the 
health  room  or  the  principal's  office.  A  bell  is  rung  indicat- 
ing the  nurse's  arrival.  A  school  janitress  or  a  good  prin- 
cipal's clerk  may  be  of  great  assistance  in  getting  the  chil- 
dren ready.  Each  child  will  come  with  his  health  record 
card  in  a  fold  of  clean  paper,  and  on  this  paper  may  be 
written  the  teacher's  reason  for  sending  in  the  pupil.  He 
may  be  suspected  of  some  ailment,  or  the  teacher  has  noticed 
that  he  is  not  getting  the  treatment  previously  recommended, 
or  for  many  other  reasons,  except  as  punishment.  The 
nurse  inspects  the  child,  and,  unless  he  is  excluded,  sends 
him  back  to  his  room,  with  a  note  to  the  teacher  about  the 
case  on  the  same  folder-protector  of  the  card.  The  teacher 


MEDICAL  INSPECTION  PLAN  327 

may  clip  small  memoranda  slips  on  cards  of  pupils  who  have 
not  yet  obtained  treatment,  or  put  these  cards  in  a  special 
part  of  her  file,  or  she  may  use  the  various  colored  clip- 
markers  for  card  indexes,  each  color  of  which  may  be 
given  a  standard  meaning,  as  before  mentioned. 

The  symptom  chart  prepared  by  Dr.  E.  B  .  Hoag  and 
printed  in  his  "Health  Index  of  Children,"  and  separately, 
or  some  other  set  of  indices  to  school  ailments,  such  as  are 
used  in  Cleveland,  or  printed  by  the  writer  in  American 
Education,  or  those  given  by  Dr.  Wood  in  his  "Health 
and  Education,"  will  be  of  great  assistance  to  the  teachers 
in  locating  the  children  needing  referring  to  doctor  or 
nurse.*  Most  of  the  present  work  of  medical  inspection 
is  really  teacher-inspection,  since  most  of  the  cases  are  first 
noticed  by  the  teachers  and  then  sent  in  to  the  doctors. 
With  all  this  responsibility  the  teachers  have  not  been  given 
a  square  deal  in  the  way  of  health  instruction  in  the  form 
of  lectures,  clinics,  teachers'  meetings,  or  books,  by  which 
to  fit  themselves  for  their  serious  responsibility;  and  their 
normal  or  college  courses  have  never,  in  most  probability, 
even  touched  upon  such  matters.  "The  child,"  to  their  pro- 
fessional training  institutions,  was  quite  largely  a  disem- 
bodied mentality,  and  psychology  was  the  only  study  of  his 
nature. 

2.  Environmental  Inspections 

After  pupil  inspections,  according  to  our  outline,  come 
environmental  inspections.  Home  visits^  or  home  hygiene 
inspection,  by  nurses  is  about  their  most  important  work, 
and  the  problem  of  school  sanitation  will  soon  come  up  in 
any  thorough  system  of  medical  supervision.  The  home- 
hygiene  inspections  at  the  time  of  the  nurse's  home  visits 
are  becoming  exceedingly  valuable  citizen-making  institu- 
tions, and  no  words  here  can  indicate  the  spirit,  the  pos- 
sibilities or  the  methods  of  that  humane  and  scientific  work. 

*See  also  the  bulletin  of  the  U.  S.  Bureau  of  Education,  No.  524, 
pp.  130-131. 


328     SCHOOL  HEALTH  ADMINISTRATION 

We  arrange  for  the  records  of  such  visits  in  cipher  on 
each  individual  record  card.  Each  nurse  should  obtain 
Dr.  Hoag's  or  Dr.  Cornell's  book,  and,  at  least,  a  book 
probably  now  published  by  the  first  school  nurse  of  America, 
Miss  Lina  L.  Rogers,  R.  N.,  now  superintendent  of  school 
nurses  at  Toronto,  and  formerly  of  New  York  City.  Dr. 
Dresslar's  book  on  School  Hygiene  is  also  a  desirable  volume 
on  the  whole  field.  (Miss  Rogers  is  now  Mrs.  L.  R. 
Struthers.) 

In  certain  small  cities  the  experiment  has  been  suc- 
cessfully tried  of  making  the  nurse  the  attendance  officer 
also  (thus  saving  another  salary  as  related),  so  that  she  can 
go  to  a  home  and  handle  a  case  of  truancy  effectively,  as 
any  other  school  "case."  The  possibilities  have  not  yet  been 
half  discovered  in  this  whole  field  of  home  visiting.  Even 
where  there  are  attendance  officers,  the  nurse  becomes  their 
most  valuable  assistant. 

School  sanitation  inspection  is  more  naturally  the  work 
of  the  superintendent,  director  of  hygiene,  principal  and 
business  manager;  but  the  nurse  and  the  physician  should 
know  enough  about  the  subject  from  such  texts  as  Shaw's 
or  Dresslar's  books  on  "School  Hygiene,"  or  the  other 
books  mentioned,*  to  do  effective  work  in  calling  to  their 
attention  as  often  as  is  necessary  evil  conditions  of  lighting, 
cleaning,  heating,  ventilating,  the  condition  of  toilets,  the 
necessity  for  play,  playgrounds,  and  play  apparatus,  sanitary 
drinking  fountains,  the  proper  kind  of  dusting,  and  all  such 
matters. 

The  Board  of  Health  of  Philadelphia  has  a  special  card 
form,  for  recording  the  facts  of  school  sanitation,  and  Dr. 
Hoag  has  a  portion  of  his  book  and  a  pamphlet  devoted  to 
a  "Sanitary  Survey  of  Schools,"  which  is  of  great  assist- 


*Dr.  Jesse  D.  Burks  and  his  wife  have  published  a  new  book  en- 
titled "Health  and  the  School,"  and  the  writer  has  one  under  way 
entitled  "School  Health,"  as  well  as  a  large  volume  by  a  large  group  of 
specialists  entitled  "Educational  Hygiene"  from  kindergarten  to  uni- 
versity. The  Burks'  book  is  unique,  being  in  dialogue  form.  Terman  & 
Hoag  will  soon  have  out  a  valuable  volume  on  "Health  Work  in  the 
School."  We  need  still  more  volumes — on  School  Clinics,  on  School 
Nursing,  on  Medical  Supervision,  etc. 


MEDICAL  INSPECTION  PLAN  329 

ance  to  the  amateur,  and  which  can  be  had  of  Whitaker 
and  Ray-Wiggin  Co.,  San  Francisco,  or  Paul  Hoeber  Co., 
69  East  59th  St.,  New  York  City.*  Quite  frequently  the 
nurse  or  the  school  physician  will  observe  unhealthful  condi- 
tions not  noticed  by  teachers  or  principals,  and,  then,  may 
be  even  more  successful  than  they  in  remedying  these  condi- 
tions. It  depends  upon  who  has  the  ability  to  translate 
private  opinion  into  public  opinion,  and  private  scientific 
knowledge  into  public  action. 

C.  Examinations. 

There  is  no  need  of  calling  these  physical  examinations, 
except  where  the  word  examination  is  (badly)  used  for  in- 
spection. We  have  suggested  that  a  thorough,  routine  room- 
inspection  of  children  for  all  ailments  of  a  serious  character, 
recorded  on  the  health  record  cards,  is  very  much  like  an 
examination.  It  is,  however,  not  so  individual,  so  intensive, 
and  so  technically  diagnostic.  Inspections  will  frequently 
overlook  decayed  teeth  entirely,  and  will  never  include 
routine  vision  or  hearing  tests,  nor  will  they  ever  require, 
perhaps,  the  stripping  of  each  child  to  the  waist,  as  a  mat- 
ter of  routine  and  without  suspicion  of  some  heart  or  lung 
ailment.  An  examination  should  be  a  patient,  scientific, 
investigation  of  a  child's  health  status,  regardless  of  whether 
he  is  suspected  of  an  ailment.  Such  examinations  should  not 
be  painfully  long,  and  impractical,  however,  in  their  min- 
utiae. Quick,  accurate  and  thorough  observation  and  judg- 
ment can  be  developed  in  this  field  as  in  any  other.  Much 
will  depend  upon  the  physician  and  the  nurse  and  what 
they  have  in  their  minds  as  questions  and  problems  regard- 
ing each  child's  health  condition. 

The  examinations  should  be  made  in  the  health,  or 
medical,  room.  This  should  be  about  half  the  size  of  an 
elementary  school  room  (25  by  16),  and  be  well  lighted. 
It  should  have  both  hot  and  cold  running  water,  a  toilet 
adjacent,  facilities  for  a  combination  tub  and  shower  bath, 


*See  also  the  New  Jersey  form  of  114  points  in  the  U.  S.  Bulletin, 
No.  524,  pp.  127-9. 


330    SCHOOL  HEALTH  ADMINISTRATION 

a  couch,  several  chairs,  an  ante-room  for  those  awaiting  ex- 
amination, filing  cabinets  for  case  cards  (for  systems  need- 
ing them),  a  table  or  desk  or  two  with  drawers,  a  medicine 
cabinet,  a  white  enameled  iron  and  glass  stand,  white  enamel 
wash  basins,  and  the  various  test  cards,  medicines,  and  the 
like,  needed  by  nurse  and  physician.  Types  of  equipment 
and  supplies  are  given  in  a  former  chapter.  Many  schools 
add  to  these  a  platform  scale,  usually  a  "Jones,"  with  height 
standard  attached.  Its  necessity  as  a  matter  of  general 
routine  for  all  school  children  is  yet  to  be  demonstrated, 
however. 

THE  METHOD  OF  THE   EXAMINATIONS 

As  suggested,  it  will  probably  be  best  for  the  nurse  to  be 
present  each  day  during  the  two  hours  or  more  of  the 
examination,  so  she  can  confer  with  the  physician  over  cases 
and  help  in  handling  the  children,  making  the  vision  and 
hearing  tests,  taking  the  records,  etc.,  as  can  best  be  ar- 
ranged. Scientific  management  in  business  does  some  of  its 
best  work  with  seemingly  minor  details  of  daily  practice. 
There  is  great  opportunity  for  the  practice  of  its  principles 
in  medical  supervision  and  especially  in  the  examinations. 
This  plan,  however,  must  limit  itself  to  bare  essentials,  in 
order  not  to  exceed  all  space  limits. 

We  have  urged  that  the  vision  and  hearing  examinations, 
once  a  year  or  less  often,  as  is  found  better,  be  given  by  the 
nurse  and  not  by  other  persons;  and  that  she  do  this,  as 
much  as  possible,  at  the  time  the  physician  of  her  district 
makes  his  two-hour  daily  visit  to  some  one  school.  One 
nurse  will  work  with  the  physician  at  all  times  while  the 
extra  nurses  will  devote  themselves  to  inspections  and  home 
visiting. 

Here,  at  the  ringing  of  the  bell  which  indicates  the 
physician's  arrival,  or  before,  children  suspected  of  having 
serious  ailments  or  who  for  some  reason  require  immediate 
attention  are  sent  by  the  teachers  or  nurse  to  the  health 
room.  At  the  same  time,  pupils  of  the  lowest  grades,  a 
room  at  a  time,  are  sent,  by  threes,  to  the  health  or  medical 


MEDICAL  INSPECTION  PLAN  331 

(inspection)  room.  The  nurse  quickly  inspects  the  serious 
cases,  referring  such  as  are  puzzling  to  the  doctor  for 
further  inspection,  and  then  disposes  of  the  first  group.  If 
desired,  they  may  be  examined  at  this  time. 

She  then  prepares,  as  may  be  necessary,  a  child  (of  the 
three  mentioned)  for  the  doctor's  examination,  calling  his 
attention  to  any  ailments  or  history  of  the  child  familiar 
to  her  and  necessary  for  him  to  utilize,  and  begins,  herself, 
to  test  the  vision  and  hearing  of  another  child.  By  the  time 
the  doctor  is  through  with  his  medical  examination  she  will 
perhaps  be  through  with  these  two  tests,  and  all  can  be 
recorded  on  the  health  record  card  of  the  pupil,  exclusions 
can  be  made,  or  notices  to  parents  regarding  serious  physical 
defects  or  other  ailments  signed.  Each  case  (name  of  child) 
will  be  placed  in  her  case  book,  or  on  a  case-card  on  file  in 
the  health  room  or  principal's  office.  Such  cards  for  de- 
fective pupils  are  found  necessary  in  many  cities.  The  one 
used  by  Newark  is  sent  to  the  ''department  of  medical  in- 
spection," when  the  case  is  concluded.  Cards  not  sent  in  by 
the  end  of  the  school  term  are  used  for  follow-up  work  in 
the  summer.  Whenever  a  case  is  concluded,  the  teacher 
should  be  notified.  The  word  "case"  is  frequently  used  to 
mean  both  a  single  child  and  all  his  ailments  at  any  one 
time,  and  again  each  one  of  the  ailments  found,  so  that  a 
child  might  be  six  or  more  cases  at  once.  If  the  term  is 
used  (and  it  probably  should  not),  it  should  refer  only 
to  one  child  with  all  of  his  ailments,  whether  one  or  many, 
at  any  one  time.  Usually  every  new  ailment  he  gets  will 
make  another  case.  Then  instead  of  recording  the  number 
of  "cases,"  the  number  of  different  ailments  should  be  given, 
and  for  a  large  group  of  children  there  will  always  be  more 
ailments  than  pupils,  probably,  on  the  average,  two  or  more 
to  one. 

The  time  of  the  examination  should  preferably  be  from 
nine  to  eleven  each  day,  and  each  day  in  a  different  school 
during  a  week  or  longer,  depending  upon  the  number  of 
schools  it  takes  to  supply  about  three  thousand  children,  de- 
pending somewhat  upon  the  locality,  of  course.  Perhaps 


332     SCHOOL  HEALTH  ADMINISTRATION 

two  thousand  for  the  doctor  and  the  same  or  fewer  for  the 
nurse  may  be  found  desirable  in  a  poor,  foreign  district. 
For  small  schools  the  doctor's  visits  should  be  distributed 
over  the  year.  A  school  with  200  pupils  will  mean  about 
10  visits,  or  one  every  three  or  four  weeks.  Compromises 
may  be  made  here. 

If  the  nurse  and  doctor  go  to  the  same  school,  how  can 
we  have  inspection  at  other  schools  each  day,  someone  may 
ask?  This  is  one  of  the  reasons  for  the  extra  nurse  in  the 
typical  city.  She  will  do  this  work.  Otherwise,  the  prin- 
cipals and  teachers  must  use  their  discretion  as  they  have 
done  for  so  long,  until  the  nurse  can  come  in  the  late  morn- 
ing or  in  the  afternoon.  Some  of  these  daily  inspection 
visits  she  can  avoid  by  telephoning  to  a  school  and  finding 
whether  the  teachers  have  looked  and  found  any  urgent 
cases.  On  schedule,  she  will  probably  get  to  one  or  two 
of  these  other  schools  each  afternoon  anyway. 

THE  VISION  EXAMINATION 

Whether  vision  and  hearing  tests  should  be  made  each 
year  is  a  question.  Abroad,  all  examinations  are  less  fre- 
quent than  here.  A  modification  of  the  plan  of  Meriden, 
Connecticut,  commends  itself  to  our  judgment,  as  a  tentative 
hypothesis :  that  of  tests  for  new  children  whenever  they 
enter  the  school  above  the  kindergarten,  and  every  other 
year  thereafter,  i.  e.,  the  first,  third,  fifth,  seventh,  ninth, 
etc.  The  three-year  interval  there  practiced  would  seem 
too  long. 

For  the  method  of  the  examinations  in  detail,  nurses  and 
doctors  should  refer  to  some  such  book  as  that  of  Dr. 
W.  S.  Cornell  (Health  and  Medical  Inspection  of  School 
Children).  Whipple's  methods  given  in  Monroe's  Cyclo- 
pedia of  Education  under  the  topics,  "Ear"  and  "Eye," 
are  also  commended.  The  methods  given  in  Gulick  and 
Ayres'  Medical  Inspection  of  Schools,  are  well  chosen. 
With  all  their  defects  as  complete  tests,  the  Snelling's  or 
other  test  types  for  capacity  to  read  at  twenty  feet,  and  for 
astigmatism,  must  be,  until  we  get  better  trained  nurses  and 


MEDICAL  INSPECTION  PLAN  333 

physicians  for  this  work,  our  chief  reliance.  The  ap- 
paratus recommended  by  Whipple  consists  of:  a  test  card 
for  acuity,  a  test  card  for  astigmatism  (preferably  Ver- 
hoeff's  chart),  a  simple  trial  frame  into  which  may  be  fitted 
during  the  examination  either  one  or  two  minus  .75  d  and 
one  or  two  plus  .75  d  spherical  lenses  (48-inch  focus, 
English  system),  and  one  blank  disk.  Probably  better  than 
the  trial  frame  into  which  may  be  set  the  two  types  of  lenses, 
are  cheap  spectacle  frames  fitted  up,  respectively,  with  the 
plus  and  minus  glasses.  These  are  for  those,  however,  who 
have  the  interest  to  go  forward  and  do  accurate  work,  and 
will  probably  be  used  only  where  there  is  a  director  of 
hygiene.  Another  instrument,  the  retinoscope,  the  shape  of 
a  small  paddle  with  a  mirror  and  letters  on  its  face,  tests  for 
three  types  of  defects,  and  is  good  for  quick  general  diag- 
nosis for  those  who  learn  how  to  use  it. 

But  just  as  important  as  the  test,  is  the  examination  of 
the  general  condition  of  the  pupil's  eyes,  whether  inflamed, 
crossed,  seemingly  strained,  whether  the  child  has  frequent 
headaches,  how  he  holds  his  head,  as  well  as  the  note  by 
the  teacher  which  she  places  on  the  paper  in  which  each 
child  carries  his  examination  card. 

Place  the  test  card  in  a  good  light  at  a  distance  of 
twenty  feet  on  the  level  with  the  pupil's  eyes,  and  stand  the 
child  in  such  a  way  as  to  avoid  any  reflected  glaring  light. 
Children  wearing  glasses  are  to  be  tested  with  the  glasses 
on,  and  if  normal  with  them,  so  recorded.  Pupils  who,  at 
twenty-foot  distance,  cannot  read  the  line  of  letters  marked 
twenty  feet  should  not  be  counted  defective  (unless  there 
are  other  signs  of  eye  strain  and  ocular  defect) .  Only  those 
whose  vision  in  either  eye  is  20/40  or  less  (each  eye  always 
tested  separately  and  then,  perhaps,  both  together)  should 
be  counted  defective,  with  the  exception  mentioned.  Test- 
ing with  both  eyes  open  has  the  advantage  of  showing  what 
the  best  vision  of  the  child  is  in  ordinary  circumstances,  but 
also  the  disadvantage  that  it  measures  principally  the  vision 
of  the  stronger  or  better  eye.  As  a  check,  it  may  be  omitted 
as  a  routine  matter,  perhaps,  and  each  child  studied  as  a 


334    SCHOOL  HEALTH  ADMINISTRATION 

separate  problem.  If  both  eyes  always  varied  together, 
mechanical  methods,  almost,  might  be  employed.  Untor- 
tunately,  the  children  strain  and  accommodate  their  eyes 
during  the  test.  The  best  statement  of  the  whole  problem 
here  is  perhaps  that  given  by  the  head  of  the  vision  de- 
partment of  the  school  clinic  at  Dunfermline,  Scotland,  in 
the  1911-12  report,  distributed  so  freely  by  the  Carnegie 
Trust  of  that  place.  The  following  pupils,  as  a  general 
rule,  should  be  referred  as  possibly  defective  and  in  need 
of  the  attention  of  an  oculist: 

a.  All  pupils  showing  signs  of  eyestrain,  inflammation, 
headaches,  etc. 

b.  All  pupils  with  vision  20/40  or  less  in  either  or  both 
eyes. 

English  and  Scotch  reports  usually  give  the  following 
in  the  report: 

1.  Number  at  different  ages  with  "normal,"  20/20,  vision. 

2.  Number  at  different  ages  with  "good,"  20/30,  vision. 

3.  Number  at  different  ages  with  "fair,"  20/40,  vision. 

4.  Number  at  different  ages  with  "bad,"  20/60,  vision. 

The  data  by  sexes  are,  also,  frequently  given,  although 
probably  unnecessarily.  Most  children  are  reported  to 
parents  who  are  20/40  or  less.  The  following  for  all  the 
pupils  of  Dunfermline  shows  either  an  improvement  in 
visual  conditions,  or  a  change  in  methods  by  the  examiners, 
or  both: 

1910.  1911-12. 

Boys   20/40  or  worse 6.4% 5.1% 

Girls 20/40  or  worse 12.5% 7.4% 

The  duty  of  the  nurse  is  to  get  those  books  which  will 
help  her  best,  and  also  to  obtain  help  from  oculists,  and  to 
visit  other  school  systems  with  good  medical  supervision 
systems.  No  plan  can  take  the  place  of  a  live,  inquiring, 
sympathetic  intelligence. 

HEARING  TESTS 

As  the  eyes  were  tested  singly  so  is  the  hearing  of  each 
ear.  The  whisper  test  and  the  stop-watch  tests  will  be  of 
value.  As  with  vision,  the  individuality  of  children  is  such 


MEDICAL  INSPECTION  PLAN  335 

that  the  best  standard  yet  is  common  sense,  conservative 
common  sense  in  this  matter.  The  tragus  or  projecting  por- 
tion of  the  ear  may  be  pressed  easily  into  the  cavity,  and 
the  stop-watch  started  and  stopped  and  the  child,  not  seeing 
it,  asked  if  he  hears  it.  What  is  asked  may  be  whispered 
quite  softly.  Numbers  and  short  sentences  may  be  used. 
The  standard  may  be  an  ordinary  soft  whisper  at  the  dis- 
tance of  the  vision  tests,  twenty  feet,  this  probably  being 
the  greatest  length  of  the  room  used.  Only  a  very  few 
children  in  each  school  will  probably  be  found  with  this  ail- 
ment, usually  preceded  by  discharging  ears. 

All  three  or  four  of  the  children  awaiting  examination 
may  be  tested  at  once  by  standing  them  with  their  backs 
to  the  nurse  and  whispering  commands,  or  asking  that  all 
who  hear  the  stop-watch  at  various  distances  hold  up 
their  hands,  etc.  The  difficulty  of  one  pupil  imitating  an- 
other may  easily  be  overcome.  The  growing  experience  of 
the  nurse  gives  a  norm  or  standard  probably  of  more  value 
than  that  of  an  audiometer,  though  the  development  of 
such  objective  standards  should  be  encouraged  in  all  this 
work.  The  observations  of  the  teacher  and  parent  as  to 
the  children's  condition  should  always  be  sought  as  a  help 
in  examination. 

Both  examinations  have  taken  less  time,  of  course,  than 
to  read  the  lines  here  given  in  explanation  of  the  work, 
probably  two  to  five  minutes  for  each  pupil,  making  records 
and  all. 

THE  DOCTOR'S  MEDICAL  EXAMINATION 

The  child  having  been  tested  for  hearing  and  vision  and 
the  results,  if  below  20/40,  placed  on  the  record  card  for 
each  eye,  or,  the  numerical  record  for  any  degree  of  de- 
fect as  may  seem  better,  he  passes  on  to  the  physician  who 
gives  him  a  thorough  medical  examination,  loosening  the 
clothing,  removing  the  coat,  or  even  stripping  him  as  ap- 
pears necessary  for  the  best  examination.  The  parents  of 
twenty  or  more  children  have  been  notified  of  the  approach- 
ing examination  on  this  day  and  it  is  desirable  that  as  many 


336    SCHOOL  HEALTH  ADMINISTRATION 

come  as  possible.  If  a  parent  is  present,  all  the  children  of 
the  family  in  that  school  should  be  examined  on  that 
morning. 

The  doctor  looks,  not  for  a  few  ailments,  but  for  all  on 
the  code  and  report  list.  Some  of  the  more  easily  missed 
ailments,  he  will  give  particular  attention  to,  and  especially 
those  placed  in  the  upper  part  of  the  list  of  physical  de- 
fects. If  a  doctor  finds  few  cases  of  enlarged  glands  one 
year  and  then  later  learns  of  their  possible  harm  to  the  child 
in  his  school  work,  it  has  been  found  in  our  study  that  he 
will  then  begin  to  find  many  cases  where  he  had  not  seen 
them  before.  What  a  man  is  so  sees  he,  is  the  law  of  medical 
perception. 

The  doctor,  especially,  must  be  careful  to  calm  the  fears 
of  the  children  and  put  them  at  their  ease.  It  is  all  too 
customary  a  habit  for  children  to  remain  out  of  school  on 
the  days  when  they  know  that  the  doctor  is  coming.  Some 
teachers  use  the  doctors  as  disciplinary  bogeys,  a  great 
mistake.  English  school  physicians  may  go  about  with  silk 
hats  and  frock  coats,  but  many  of  them  carry  a  bag  of  candy 
("sweets")  of  which  to  give  to  each  child  examined.  One 
of  them  who  has  written  a  book  on  the  work  says  it  has 
many  advantages.  The  attitude  is  the  important  thing. 

As  the  doctor  makes  his  examination  he  records  any  seri- 
ous findings  needing  attention  by  parents  and  family  phy- 
sicians on  the  health  record  card.  The  system  of  signs  makes 
it  possible  to  do  this  very  rapidly  and  with  little  waste  of 
time.  Here  has  been  one  of  the  greatest  leaks,  and  almost 
as  great  as  that  of  having  the  doctor  travel  about  from 
school  to  school  every  morning  on  inspection  tours,  in  many 
of  the  present  systems  of  so-called  "medical  inspection." 

Whenever  a  referable,  non-infectious  ailment  is  found 
in  the  examination  or  the  inspections,  the  following  note  to 
parents  may  be  filled  out  from  the  cards  and  inclosed  in  an 
envelope  by  the  nurse,  after  the  examination  is  over  some- 
where near  eleven  o'clock: 


MEDICAL  INSPECTION  PLAN  337 

Medical  Supervision  of  Schools, 
Montclair,  N.  J. 

NOTICE  TO  PARENTS  OR  GUARDIANS. 

This  notice  does  NOT  exclude  the  pupil  from  school. 

Date ,  191. . 

The  parent  or  guardian  of 

is  hereby  informed  that  a  physical  examination  by  the  school  physician 

seems  to  show  that  this  child  is  suffering  from 

You  are  advised  to  take 

this  child  to  your  family  physician  or  a specialist, 

for  advice  and  treatment  as  soon   as  possible,  in  order  that  the  pupil 
may  be  better  fitted  to  do  successfully  and  without  injury  his  school  work. 

School  Physician. 

This  notice  may  be  placed  on  a  card  of  a  certain  color, 
say  yellow,  and  about  5^  by  3>4  inches  in  size.  Some 
send  all  such  messages  by  post,  but  this  is  in  most  cases  a 
needless  waste. 

On  the  back  of  the  card  may  be  printed  a  permit  by  the 
parent  for  the  nurse  to  take  the  child  to  a  clinic  or  physician 
for  medical  or  surgical  treatment,  and  an  alternative  state- 
ment that  the  parent  has  had  a  physician  and  the  result  of 
the  visit,  somewhat  as  follows  : 

PLEASE    SEE   THAT    THIS   CARD    IS   RETURNED   TO   THE   TEACHER. 

This  pupil  was  seen  by  Dr on 

,  19 . . . . ,  with  the  following  result 


Signature  of  parent  or  guardian, 
I  desire  the  school  nurse  to  escort  my  child  to. 


for  medical  or  surgical  treatment  of  the, 
Signature  of  parent  or  guardian, 


338     SCHOOL  HEALTH  ADMINISTRATION 

If  the  parent  does  not  respond  within  three  days,  and  an 
inspection  at  that  time  by  the  nurse  shows  no  evidence  of 
satisfactory  treatment,  another  notice  should  be  sent. 

If  this  notice  is  not  heeded,  and  it  should  be  printed  and 
worded  in  such  a  manner  as  to  command  attention  and  get 
results,  the  nurse  may  visit  the  home  to  help  the  parent  see 
the  need  of  the  treatment  or  to  explain  and  arrange  with 
her  the  free  treatment  at  some  dispensary,  the  school  clinic, 
or  other  similar  place.  If  the  nurse  is  unable  to  get  the 
treatment,  and  cannot  do  it  herself,  the  physician,  principal 
or  teacher  may  attempt  the  matter. 

So  many  parents  are  so  poor  and  so  ignorant,  and  the 
provisions  for  treatment  are  so  inadequate  or  unsatisfactory, 
that  men  and  women  in  the  school  medical  service  are  soon 
driven  to  see  the  absolute  necessity  of  an  adequate  school 
clinic,  with  an  oculist  to  make  eye  examinations  and  pre- 
scribe and,  at  times,  furnish  free  glasses,  dentists  for  dental 
service,  and  surgeons  for  operative  work.  The  surgeons 
or  the  nurses  attached,  or  a  school  physician,  can  make  such 
treatments  as  are  necessary — those  for  ringworm  of  the 
scalp  with  X-rays  possibly,  for  favus,  for  trachoma,  ade- 
noids, tonsils,  etc.,  and,  with  the  help  of  the  physical  educa- 
tion division,  such  medical  gymnastics  as  are  needed  for 
orthopedic,  mouth  breathing,  and  other  cases.  The  need 
for  an  open-air  school,  and  outdoor  cooler  ("uncooked") 
and  moister  air  in  the  classrooms,  will  also  soon  be  made 
manifest  in  even  the  best  of  cities. 

As  the  examinations  extend  through  the  entire  year, 
and  the  graduating  class  of  February  may  not  be  reached 
by  that  time,  it  will  be  well  to  give  this  class  an  examina- 
tion early  in  the  term.  Other  children  who  may  also  be 
examined  out  of  turn  are:  the  children  of  a  family  when  a 
parent  has  come  to  the  examination,  as  suggested,  children 
going  into  athletic  contests  (very  important  in  some  cities), 
children  who  are  especially  referred  to  the  physician  by  the 
nurse,  or  to  the  nurse  by  the  teacher,  and  children  who  have 
entered  school,  or  that  school,  for  the  first  time  after  the 
pupils  of  their  rooms  have  been  examined. 


MEDICAL  INSPECTION  PLAN  339 

Not  only  parental  visiting  at  the  examinations  is  desira- 
ble but  also  school  consultations  with  nurse  or  physician, 
when  the  parent  has  neglected  treatment  for  the  child,  for 
instance.  A  notice  such  as  the  following  may  be  sent,  at  the 
end  of  the  three-day  period  mentioned: 

DEPARTMENT  OF  MEDICAL  SUPERVISION  OF  SCHOOLS. 

Date ,   19 

To  the  parent  or  guardian  of 

Public  School 

You  were  notified  a  few  days  ago  that  this  child  was  found  on 
examination  by  the  school  physician  nurse  to  be  in  need  of  immediate 
treatment  for 

Please  call  at  the  school  at o'clock 

to  confer  with  the  school  physician  nurse. 

Principal. 

Cross  out  either  "physician"  or  "nurse"  where  they  are 
printed  for  alternative  use.  This  card  may  be  white  in 
color  and  3^  by  5^  inches  in  size.  Other  devices  to 
obtain  treatment  will  be  invented  by  the  thoughtful  and 
interested  nurse,  physician,  or  principal.  Some  cities  use 
attendance  officers  to  force  children  in  whom  the  doctor  or 
nurse  will  not  admit  till  treated  or  cured.  Notice  is  also 
sometimes  sent  that  parents  are  keeping  children  out  illegal- 
ly, even  though  excluded  or  referred  for  treatment. 

When  the  time  has  come,  three  days  after  notification, 
and  the  pupil  is  in  school,  the  teacher  sends  the  pupil  in 
for  the  nurse's  or  physician's  inspection  to  see  if  the  cure 
has  been  obtained.  No  record  of  cure  or  treatment  is  ever 
to  be  made  without  such  inspection.  The  teacher's  opinion 
is  not  enough.  Dr.  Foster,  of  Oakland,  Cal.,  has  his  nurses 
record  cures  at  the  first  routine  inspection  only,  and  these 
for  ailments  found  the  year  previous.  Cures  take  time. 

A  further  attempt  at  accuracy,  co-operation,  and  a  check 
on  the  work  of  doctor  and  nurse,  is  the  principal's  monthly 
report  based  upon  his  own  and  the  teachers  records.  This 
will  be  described  later. 


340    SCHOOL  HEALTH  ADMINISTRATION 

Great  care  must  be  taken  not  to  give  the  impression 
that  the  nurse  and  physician  are  interested  in  providing 
patients  for  the  doctors,  dentists  and  oculists  of  the  town. 
They  are  not;  and  one  of  the  great  reasons  for  the  school 
clinic  is  to  break  down  this  argument  not  only  of  the  medi- 
cal fakirs  so  busy  everywhere  just  now,  but  also  the  plain 
common-sense  parents  of  the  children.  Dr.  Chapin  of  the 
Providence  Board  of  Health  in  his  1910  report  and  again 
in  the  one  for  1911  has  met  a  number  of  the  criticisms 
of  such  free  treatment,  especially  that  it  would  injure  the 
pocket-books  of  private  medical  people. 

It  is  probable  that  if  all  the  children  of  the  nation  were 
given  free  medical  attention  and  treatment  until  the  age 
of  sixteen,  as  is  almost  the  case  now  in  Boston  since  the 
completion  of  the  Forsythe  Dental  Clinic,  and  all  children 
educated  in  right  health  habits  and  the  necessity  of  getting 
the  help  of  dentist  and  doctor  where  their  services  are 
necessary,  the  medical  profession  as  a  whole  would  lose 
but  little,  and  the  nation  as  a  whole  would  be  immeasur- 
ably improved.  Free  schools,  free  text-books,  free  libraries, 
free  baths,  free  music  in  the  parks,  free  postal  service,  free 
medical  service  for  old  and  decrepit  already:  and  why 
not  free  treatment  where  necessary,  and  rather  generously, 
for  the  young  and  plastic,  before  they  lose  all  their  per- 
manent teeth,  perhaps,  or  the  use  of  an  eye,  or  the  hearing 
of  an  ear?  The  bugaboo  of  ''Socialism"  hurled  in  1828 
at  the  speaker  for  free  schools  on  the  court  house  steps 
of  Philadelphia  leading  to  his  arrest,  and  used  so  freely 
ever  since,  provokes  no  fright  any  more  in  the  hearts  of 
those  who  would  minister  to  the  health  and  happiness  of 
this  people.  Selfishness  will  be  swept  into  its  deserved 
oblivion,  before  this  advancing  democracy  and  scientific 
brotherly  love.  Compulsory  school  attendance  involves  free 
and  compulsory  health  provisions.  These,  when  established, 
will  point  to  certain  necessary  social  reforms,  of  a  far-reach- 
ing character,  probably  socialistic  in  tendency. 


MEDICAL  INSPECTION  PLAN  341 

VACCINATION    FOR    SMALL    POX 

No  one  has  yet  proved  that  small  pox  vaccination  is 
not  necessary  or  desirable  for  all  school  children.  Many 
cities  are  experimentally  doing  without  such  requirements 
in  the  schools,  and  the  ailment  does  not  seem  to  get  a 
start  in  such  towns.  However,  much  experience  points  to 
its  value  even  if  the  disease  seems  to  be  losing  its  virulence, 
and  probably  the  best  plan  to  enforce  is  that  no  child  shall 
be  admitted  to  the  schools  a  day  without  such  vaccination. 
Free  vaccination  should  be  provided  by  the  schools  or  board 
of  health  for  such  purpose,  and  the  work  done  by  the 
nurse  or  physician.  Re-inspection  to  observe  the  effect  of 
the  vaccine  should  be  made  as  in  the  case  of  other  treat- 
ments. Here  the  nurse  will  often  find  it  necessary  to  make 
dressings  for  the  vaccination  sores.  In  Philadelphia,  ac- 
cording to  Burks,  laxity  in  the  prevention  of  small  pox 
cost  the  city  in  1891-2  through  an  epidemic  over  $21,000,- 
ooo,  and  another  outbreak  in  1912  in  Pennsylvania  towns 
was  only  checked  by  wholesale  vaccination. 

EDUCATION    OF    THE    PARENTS 

For  many  or  most  of  the  fifty-four  ailments  and  classes 
of  ailments  parents  can  be  given  judicious  health  instruc- 
tion, as  to  treatment,  reference  to  doctors  and  prevention. 
The  book  by  Dr.  Ditman  on  "Home  Hygiene  and  the 
Prevention  of  Disease,"  by  Duffield  and  Co.,  or  one  just  as 
good  or  better,  if  any,  should  probably  be  in  every  intelli- 
gent household.  Much  of  our  recently  discovered  health 
knowledge  has  been  the  almost  secret  possession  of  the  few. 
While  there  is  some  little  danger  in  home  treatment  there 
is  no  danger  in  home  prevention,  and  a  book  along  the 
line  of  health  education  in  the  simple  language  of  the  people 
is  necessary  to  democratize  our  health  knowledge.  This 
latter  desire  is  also  back  of  the  simpler  nomenclature  used 
in  the  present  system  of  medical  supervision.  An  examina- 
tion of  the  list  of  school  ailments  given  in  the  1910  or 
1911  reports  of  the  Boston  Board  of  Health,  and  other 
such  cities,  will  show  what  to  avoid  in  this  field. 


342    SCHOOL  HEALTH  ADMINISTRATION 

Do  you  know,  lay  reader,  what  urticaria,  verucca,  fur- 
unculus,  acne,  tinea,  scabies,  pediculosis,  and  such  names 
mean?  They  are  respectively:  hives,  warts,  boils,  black- 
heads, ringworm,  itch,  and  head  lice.  Such  terminology 
for  diseases  thrown  at  parents  is  defended  by  saying  that 
uit  scares  them  into  getting  treatments."  We  say  simply 
that  these  are  the  undemocratic  methods  of  persons  who 
do  not  know  how,  in  the  best  way,  to  educate  the  people 
into  independence  and  self-respect.  Let  schools  using  and 
adapting  this  system  get  close  to  the  people  and  their  needs 
and  their  problems,  not  high  in  the  air  above  them,  or 
behind  some  awesome  word  and  mysterious  profundity. 

We  shall  not  attempt  here  to  describe  all  the  good 
methods  now  being  used  by  schools  to  reach  the  parents, 
or  to  devise  an  ideal  and  general  plan.  For  brevity,  only 
a  list  of  some  of  the  more  interesting  attempts,  and  where 
they  can  be  found,  will  be  listed: 

1.  The  various  colored  prescription  slips  for  a  growing 
variety  of  ailments,  to  be  found  in  Newark,   Providence, 
New   York   City,    and   shown   in   "Medical   Inspection   of 
Schools,"  by  Gulick  and  Ayres,  new  edition. 

2.  The  dental  charts  showing  the  location  of  defective 
teeth,  given  out  with  defective  teeth  notices  in  many  cities, 
one  form  given  in  the  book  mentioned;   also  the  various 
pamphlets  such  as  are  given  out  by  the  Bath  Trustees,  City 
of  Boston   (on  teeth),  the  Children's  Aid  Society  of  New 
York,  the  various  pamphlets  of  Dr.  E.  B.  Hoag  of  Berke- 
ley,  California;  the  prescriptions  for  getting  compounded 
very  cheaply  serviceable  tooth  powder,   by  the   Board  of 
Health  of  New  York  City;  the  Newton,  Mass.,  Board  of 
Health  pamphlet  on  "Information  for  the  Family  in  Re- 
gard  to    Communicable    Diseases,"    etc.,    etc. 

3.  The  health  lectures  given  by  school  nurses,  doctors 
and  principals,  and  outside  specialists,   often  with  the   aid 
of  the  stereopticon.     Newark  records  346  such  lectures  in 
the  school  year  of  1910-11. 

4.  The  tuberculosis  and  other  exhibits,  stationary  and 
portable. 


MEDICAL  INSPECTION  PLAN  343 

5.  The   health   budget   exhibits  showing   the   need   for 
appropriations  for  medical  supervision  and  other  phases  of 
educational  hygiene. 

6.  Pamphlets  on  infant  and  child  hygiene  for  parents. 

7.  Pamphlets  on  sex  hygiene. 

8.  The  remarkable  variety  of  ways  described  in  Elsa 
Denison's  "Helping  School  Children,"  showing  that  "where- 
ever  there  is  a  will  there  is  a  way." 

9.  The  constant  and  varied  use  of  the  newspapers  for 
describing   school   health   needs   and  what  parents   can   do 
to  help. 

10.  The  annual  health  day  or  health  week  in  the  schools, 
as  in  Boston. 

11.  Above  all,  the  splendid  services  of  the  wide-awake 
and  resourceful  school  nurse  going  to  the  homes  and  help- 
ing the   family  in  their  struggles    with    the     real    health 
problems  of  life. 

THE  WEEKLY  REPORT  OF  DOCTOR  AND  NURSE 

Our  nurse  does  all  the  general  reporting.  Any  ade- 
quate report  will  always  show  in  juxtaposition  the  ailments 
found  by  both  doctor  and  nurse  and  what  has  been  done 
with  them,  quite  in  contrast  to  most  of  the  reports  now 
given  out  to  the  public  by  school  superintendents  or  direct- 
ing physicians. 

Some  of  the  standards  for  such  a  report  are : 

a.  It  must  be  simple  and  take  up  as  little  time  as  pos- 
sible and  yet  give  the  facts  necessary  for  the  proper  educa- 
tion of  the  public,   and  the   accurate  recording  and  study 
of  health  data  necessary  for  school  health  control. 

b.  It  must  show  the  ailments  found  in  detail,  if  possible, 
and  give  the  curative  results  obtained  by  the  department. 

c.  It  must  record  the  work  done  by  the  different  mem- 
bers of  the  corps  and  the  time  they  spend  in  the  school 
service. 

d.  It  must  use  some  standard  classification  and  nomen- 
clature of  school  ailments,   not  only    for    the    uniformity 
necessary,  and  the  ease  of  memorizing    a    relatively    un- 


344    SCHOOL  HEALTH  ADMINISTRATION 

changing  outline,  but  also  for  dividing  the  work  naturally 
and  emphasizing  by  position  those  ailments  which  play  a 
large  part  in  the  success  or  failure  of  the  pupil  in  school 
and  life. 

e.  It  must  eliminate  as  much  as  possible  the  writing-in 
of  the  names  of  ailments.  A  great  many  reports  print  only 
names  of  ailments  which  occur  with  extreme  rarity  and 
the  doctor  and  nurse  must  spend  much  time  in  writing-in 
many  ailments  or  else  neglect  to  report  them.  The  result 
is  commonly  neglect,  with  large  numbers  of  important  ail- 
ments unreported. 

/.  The  form  should  be  such  as  will  make  possible  a 
balancing  of  figures  if  possible,  somewhat  as  the  monthly 
reports  of  teachers  and  principals  are  made  to  balance. 
This  is  a  difficult  matter.  Nurses  must  learn  by  study  how 
to  make  out  the  report,  just  as  they  would  learn  to  use 
any  other  instrument,  say,  a  typewriter. 

g.  It  must  show  the  work  by  days,  and  by  the  week, 
and  must  record  both  old  and  new  ailments,  making  it  pos- 
sible for  the  superintendent  to  know  at  any  time  of  the 
year  how  many  cases  of  uncured  school  ailments  there  are 
in  the  schools  and,  perhaps,  in  any  school  district.  uOld" 
ailments  are  those  found  at  any  time  during  the  year  before 
the  week  reported.  "New"  ailments  are  those  found  dur- 
ing the  week  reported.  Daily  reporting  may  be  used  in 
large  systems,  but  we  are  dealing  with  the  more  typical 
cities  and  rural  districts. 

h.  It  must  show  the  number  of  new  ailments  found  not 
only  by  the  doctor  but  also  by  the  nurse,  their  sum,  the 
number  to  be  subtracted  because  "negative,"  left  the  city, 
refused  treatment,  etc.,  and  what  happened  to  those  left. 

i.  It  must  record  exclusions,  treatment  by  nurse  or  out- 
side agencies,  cures  found  by  re-inspection,  number  read- 
mitted, and  the  number  "improved  but  not  cured"  in  a  case 
where  cure  is  a  matter  of  months  or  years. 

;.  The  report  will  be  not  only  an  ailment  report,  but 
also  a  report  of  the  number  of  examinations,  home  visits, 


MEDICAL  INSPECTION  PLAN  345 

inspections,  pupils  taken  to  the  dispensary,  etc.  If  possible, 
the  nurse  should  report  weekly  the  total  number  of  various 
ailments  to  date  that  have  been  found,  cured,  and  not  cured, 
with  perhaps  the  number  treated  and  not  treated. 

This  will  greatly  reduce  the  work  at  the  central  office. 

k.  The  report  should  also  give  explicit  directions  as  to 
the  way  to  use  it,  and  should  interpret  all  terms  to  be  used 
that  are  shifting  in  their  meaning.  All  such  directions 
should  be  printed  on  the  report  form  itself,  if  possible. 

/.  It  should  also  provide  for  a  report  on  school  sanita- 
tion, notes  and  recommendations,  record  of  special  cases, 
and  any  other  data  that  cannot  be  given  in  figures  and 
must  be  written  out.  The  attempt  to  put  every  phase  of 
reports  dealing  with  such  intimate  and  personal  matters 
as  these  into  the  squares  of  report  forms  by  a  system  of 
checks  or  figures  easily  makes  for  mere  routine  mechanics. 
We  must  have  both  the  form  and  the  spirit,  the  technically 
definite  and  the  flexible. 

Instead  of  printing  the  large  10x15  report  here,  we  give 
the  headings  and  other  matter  necessary  to  reproduce  it. 

THE  FORM  OF  THE  WEEKLY  AND  ANNUAL  REPORT 

We  give  above  photographic  reproductions  of  the  head- 
ings of  two  sides  of  our  tentative  and  suggestive  weekly 
report.  It  can  be  modified  as  desired.  The  form  is  about 
ten  by  fifteen  inches  in  size,  and  should  be  printed  with  black 
and  red  and  with  perhaps  blue  lines  to  make  easily  dis- 
tinguishable the  various  divisions.  The  upper  half  of  the 
face  containing  the  name  of  the  city  is  the  general  summary 
of  work  done :  schools  visited,  time  spent  in  the  schools,  etc. 
The  lower  half  of  the  face  page  is  divided  vertically  by  a 
line  continuing  the  line  to  the  right  of  Wednesday  or  Thurs- 
day above.  To  the  left  of  this  line  below  should  be  printed 
specific  numbered  directions  for  making  out  the  report  such 
as  appear  below,  while  to  the  right  below  is  the  heading 
"General  Notes  to  Supervisor  of  Hygiene,"  under  which 
is  to  be  written  in  any  notes  to  supervisor,  superintendent,  or 
board  of  education  on  such  matters  as :  special  cases,  recom- 


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348     SCHOOL  HEALTH  ADMINISTRATION 

mendations,  home  hygiene,  school  sanitation,  co-operation  of 
outside  agencies,  special  health  needs  of  the  schools,  supplies 
desired,  work  of  open  air  school,  why  certain  cases  are  not 
treated,  the  chief  difficulties,  control  of  epidemics,  personal 
stories  of  cases  for  the  newspapers,  etc.,  etc. 

On  the  other  side  of  the  report  sheet  is  the  "Detailed 
Report  of  Ailments,"  the  term  ailments  covering  all  affec- 
tions of  children  of  a  pathological  character.  Vertically  on 
the  left  are  placed  the  54  classes  of  ailments  in  four  divisions 
with  three  or  four  lines  left  at  the  end  of  each  division  for 
writing  in  any  special  cases  that  cannot  be  placed  in  any  of 
the  above  divisions.  We  give  only  the  heading  and  the  side, 
but  the  report  may  easily  be  duplicated  in  full  by  extending 
the  lines.  It  looks  formidable  but  nothing  less,  it  seems, 
will  keep  before  physicians  and  nurses  the  ailments  they 
should  look  out  for;  will  make  easy  the  detailed  recording 
of  ailments;  and  will  keep  a  definite  unchanging  order  easily 
memorized  by  use.  This  report  will  be  entirely  made  out 
by  the  nurse  in  red  ink,  on  Saturday  afternoons  with  the  pro- 
viso that  it  is  to  be  in  the  hands  of  the  supervisor  or  superin- 
tendent by  Monday  at  nine  o'clock  A.M.  The  chief  weakness 
of  the  report  is  that  it  does  not  entirely  separate  the  data 
by  schools,  although  this  will  be  done  to  a  large  extent  where 
only  five  schools  are  visited  each  week  by  the  medical  ex- 
aminer, Monday  being  very  largely  the  cases  found  at  one 
school.  Records  will,  of  course,  be  kept  at  each  school  for 
the  year  and  these  may  be  called  in  at  the  end  of  the  year 
for  the  annual  report.  We  are  not  trying  here  to  provide 
a  system  for  a  large  city  like  Philadelphia  or  even  Newark 
or  Boston,  but  for  average  cities,  around  twenty  to  a  hun- 
dred thousand  population.  Dr.  Burks  has  met  the  Phila- 
delphia type  of  situation  in  his  new  book  on  Health  and  the 
School.  The  following  directions  may  be  printed  on  the 
report : 

DIRECTIONS  FOR  MAKING  THE  WEEKLY  REPORT 

i.  This  report  is  to  be  made  out  by  the  nurse  at  the  end  of  each 
day's  service  and  summarized  on  Saturday  afternoons  for  each  week 
just  passed. 


MEDICAL  INSPECTION  PLAN  349 

2.  It  must  be  delivered  at  the  office  of  the  Supervisor  of  Hygiene 
or    of    the    Superintendent    of    Schools    by    nine    o'clock    each    Monday 
morning. 

3.  Every  effort  must  be   made   to   make   it  strictly   accurate.      No 
very  minor  unreferable  ailments  should  be  recorded — only  those  which 
need  serious  attention  by  the  schools  or  the  homes  or  both;  and  every 
reasonable   effort  should  be   made   to   have   these    ailments   treated   and 
cured. 

4.  The  schools  will  be  numbered  in  arabic  numerals  and  should  be 
so   designated   on   the    reports.      (For   small   systems   with    few   schools 
the  names  of  the  schools  with  their  code  numbers  may  be   printed  in 
the  blank  space  or   spaces   at  the   top   of   the   report  under  the   words 
"General  Summary.") 

5.  Time  spent  in  the  schools  at  medical  work  will  be  recorded  in 
hours  and  decimal  parts  of  hours — two  hours  and  a  half  equalling  2.5 
hours. 

6.  Room   inspections   should  be   recorded   according  to  the  number 
of  rooms  and  not  the  number  of  pupils. 

7.  No  pupils  should  be  reported  for  more  than  one  complete   (phy- 
sical) examination  each  year.      All  other  physical  studies  of  the  pupils 
will  be  recorded  as  inspections. 

8.  New  ailments   are  those  found  during  the  week  reported;   old, 
those  previously  reported. 

9.  Under   number   of    ailments   treated   "other"    or    "O"    refers    to 
any  agencies  outside  the  schools  that  have  treated  the  pupils. 

10.  Under  "Remarks"  any  explanatory  information  may  be  written 
regarding  the   records  to  the   left.      Under  "General   Notes  to   Super- 
visor of  Hygiene"  any  general  reports,  requisitions,  special  cases,  recom- 
mendations, or  the  like,  may  be  written  in. 

11.  On  the  back  of  the  report  is  the  "Detailed  Report  of  Ailments." 
Space  is  left  for  writing  in  the  names  of  ailments  not  in  the  classifica- 
tion. 

12.  "Negative,    Subtract"    refers    to    ailments    previously    reported 
that  have  since  been  inspected  by  a  family  physician  and  declared   "no 
case"  or  not  serious  enough  to  warrant  treatment  or  operation.     Pupils 
in    any   way   leaving   permanently   the   school   system    should    also   have 
their  uncured  ailments  subtracted  from  the  previous  reports. 

13.  The  "Grand  Total  of  Number  of  Ailments  to  Date"  is  a  brief 
summary   of   the  year's   work   to  date.       In  the   "Not   Cured"   column 
should  stand  the  exact  number  of  ailments  in  the  schools  reported  on 
that  are  not  yet  cured,  so  that  the  school  officials  may  see  at  a  glance 
just   how   many    adenoid,    impetigo,    or   diphtheria    "cases"    or    ailments 
exist  at  the  time  among  the  school  children. 

14.  All  ailments  of  school  children,  especially  the  more  serious  ones, 
whether  found  in  the  schools  or  not  should   be  here  recorded.      This 
applies  particularly  to  "Infectious  Diseases." 

Is;.  If  there  is  an  assistant,  i.  e.,  one  besides  the  one  who  works 
daily  with  the  physician,  for  this  group  of  children,  she  should  report 
her  work  to  the  first  nurse  who  will  incorporate  the  data  in  this  report. 


350    SCHOOL  HEALTH  ADMINISTRATION 

CLASSIFICATION  AND  FREQUENCY  OF  AILMENTS 

We  give  below  our  classification  of  the  ailments  found 
in  the  twenty-five  cities  investigated  with  the  probable  num- 
ber of  these  ailments  which  will  be  found  in  any  one  school 
year  among  a  thousand  elementary  pupils,  more  in  the  lower 
grades  than  in  the  higher — although  we  have  shown  previ- 
ously that,  according  to  the  Newark  report  of  high  school 
ailments,  they  are  much  the  same  and  almost  as  frequent 
as  for  elementary  pupils.  The  amount  and  kind  of  varia- 
tion we  are  not  yet  ready  to  estimate. 

Probably  the  most  variable  ailments  in  the  list  are  the 
infectious;  the  frequencies  given  will  for  most  cities  merely 
indicate  the  number  of  actual  ailments  or  carriers  that  will 
be  found  in  the  schools,  and  will  not  be  large  enough  to 
give  the  medians  for  all  the  actual  "cases"  in  the  year. 
Yet  all  such  cases,  whether  found  in  the  school  or  not  should 
be  recorded.  They  cause  absence  and  lowered  vitality,  and 
various  physical  defects  such  as  weakened  vision,  defective 
hearing,  etc.,  that  are  of  much  concern  to  the  schools.  A 
first-class  system  will  also,  through  summer  nurses  and  fall 
inspections,  get  records  of  all  serious  summer  ailments  of 
the  children. 

If  each  physician  with  one  or  two  assisting  nurses  has 
three  thousand  pupils  we  can  multiply  these  frequencies  by 
three  to  see  what  the  totals  will  be  for  the  year.  Very 
great  variations  should  be  investigated,  but  may  be,  of 
course,  entirely  normal  for  those  pupils. 

There  are  about  1,419  ailments  for  the  thousand  chil- 
dren if  our  estimates  are  anywhere  near  the  true  medians 
for  average  cities.  Later  investigations  may  make  possible 
a  statement  of  reasonable  variations  from  these  average  fig- 
ures, and  may  also  show  how  they  vary  for  different  kinds 
of  cities  and  for  different  kinds  of  districts  within  cities. 
We  have  not  been  able  to  get  very  satisfactory  data  on  these 
problems.  Poor  and  foreign  families  generally  furnish  most 
ailments,  especially,  perhaps,  Russian  Jews,  South  Italians, 
and  Irish,  although  the  native  "poor  white  trash"  seem  to 
be  in  about  the  same  group. 


MEDICAL  INSPECTION  PLAN  351 

I.    NON-COMMUNICABLE  AILMENTS. 

A     Phvciral    Dpfprtc  Probable  No.  Ailments 

per  1,000  El.  Pupils 

1.  Adenoids,  nasal  obstruction,  etc 50 

2.  Anemia    10 

3.  Deafness,   defective  hearing 5 

4.  Dental,  teeth   660 

5.  Enlarged  tonsils    60 

6.  Eyesight,  vision   70 

7.  Eyes  crossed,  strabismus,  squint 7 

8.  Glands  enlarged,   adenitis IO 

9.  Heart  defects 9 

10.  Lungs  very  weak,  not  tuberculosis 5 

11.  Malnutrition,  debility,  indigestion,  general  condition.  20 

12.  Mentality    IO 

13.  Nervousness,  chorea,  habit  spasm,  nervous  exhaustion  2 

14.  Palate  defects    7 

15.  Skeleton,  orthopedic  defects  (flat-foot,  club-foot,  etc.)  2 

16.  Spine:  curvature,  posture,  round  shoulders,  etc 8 

17.  Speech:  stuttering,  stammering,  lisping,  etc 9 

B.  Common  Ailments. 

18.  Abscess,  boils,  etc 5 

19.  Acute  sore  throat,  cough,  etc 3 

20.  Bronchitis   I 

21.  Cleanliness  needed    20 

22.  Catarrh,   rhinitis    10 

23.  Colds,  bad.     Coryza 30 

24.  Ear  discharge,  otitis  media 15 

25.  Ears:  ear  wax   (impacted  cerumen),  foreign  bodies, 

etc.,   Minor    5 

26.  Eczema    7 

27.  Eyes:  "sore,"  blepharitis,  styes,  iritis,  etc.,  Minor...  20 

28.  Headache   (a  symptom),  migraine,  neuralgia 15 

29.  Laryngitis    5 


352    SCHOOL  HEALTH  ADMINISTRATION 

30.  Nose-bleed,    epistaxis    2 

31.  Pharyngitis,  chronic  sore  throat 3 

32.  Rheumatism   I 

33.  Sex  ailments  and  habits 10 

34.  Skin  ailments,  minor;  herpes,  seborrhea,  acne  (black- 

heads ) ,  etc 15 

35.  Stomatitis,  mouth  ulcers,  "canker  sores" I 

36.  Wounds,  sores,  sprains,  poison-ivy,  chilblains,  "first- 

aid,"  etc 1 50 

37.  Urinary  ailments,  incontinence  of  urine,  eneuresis...  2 

II.    COMMUNICABLE  AILMENTS. 

A.  Parasitic  and  Minor  Infectious  Ailments. 

38.  Conjunctivitis,  "pink  eye,"  etc 30 

39.  Favus,  yellow  scalp  sores I 

40.  Impetigo  "contagioso,"  infectious  sores 20 

41.  Influenza,  grippe,  infectious  colds  of  a  serious  char- 

acter     i 

42.  Pediculosis,  head  lice  and  vermin 50 

43.  Ringworm,  body  and  scalp 4 

44.  Scabies,  itch   5 

45.  Tonsilitis,  quinsy 10 

B.  Infectious  Diseases. 

46.  Chicken  pox  6 

47.  Diphtheria    2 

48.  Measles 4 

49.  Mumps    4 

50.  Scarlet  Fever 4 

51.  Trachoma,    "granulated    eye-lids" I 

52.  Tuberculosis  of  the  lungs,  "consumption" I 

53.  Tuberculosis  of  the  bones  and  other  parts  of  the  body  I 

54.  Whooping  Cough,  Pertussis 2 


Total    1,419 


MEDICAL  INSPECTION  PLAN  353 

Roughly,  I  estimate  that  about  one-third  of  the  pupils 
will  be  found  free  from  serious  ailments  (and  defects), 
another  third  will  be  found  with  teeth  defects  only,  and  the 
final  third  with  teeth  defects  and  other  ailments.  This  last 
third  will  average  about  three  ailments  each. 

PRINCIPALS'  MONTHLY  REPORTS 

On  the  regular  monthly  report  of  the  principals  to  the 
superintendent  there  should  be  required  a  statement  as  to 
the  general  status  of  the  medical  service  in  each  school  with 
a  statement  as  to  the  regularity,  punctuality,  and  fulfillment 
of  the  time  and  schedule  requirements  of  doctors  and  nurses. 
The  report  of  principals  in  Trenton,  N.  J.,  is  very  sug- 
gestive but  defeats  itself  by  its  elaborateness,  calling  for 
a  report  for  each  day  of  the  month  on  several  items  and 
the  list  of  ailments  found,  cured,  etc.,  etc.  This  is  the 
proper  work  for  the  school  nurse  and  has  been  provided  for 
in  this  plan.  The  principals  should  be  made,  however,  to 
feel  their  responsibility  for  general  oversight  and  leader- 
ship of  all  health  measures  in  their  schools  and  neighbor- 
hoods. 

CASE  CARD  SYSTEM 

The  blue  case  cards  used  in  Milwaukee  and  Newark 
and  the  one  given  in  Dr.  Cornell's  book  on  Medical  Inspec- 
tion, page  57,  are  recommended  for  study  and  use,  if  they 
are  found  necessary.  A  book  with  appropriate  headings 
on  each  page:  room,  date  found,  the  ailment,  recommenda- 
tion, results,  etc.,  for  each  school  can  more  easily  be  carried, 
and  has  some  advantages  for  a  small  system.  See  Cornell's 
Record  of  Defective  Children,  page  55.  The  exclusion 
books  will  also  give  the  record  of  a  number  of  cases.  Each 
school  should  have  its  own  exclusion-book  as  well  as  its  own 
nurse's  case  book,  or  card  index.  The  work  must  always 
be  reported  in  terms  both  of  the  number  of  children  and 
of  the  number  of  ailments. 

THE  WORK  OF  THE  TEACHERS 

Teachers  and  janitors,  of  course,  should  be  examined 
prior  to  their  entrance  to  the  school  system  and  every  two 


354    SCHOOL  HEALTH  ADMINISTRATION 

to  three,  or  fewer,  years  thereafter.  It  is  remarkably  easy 
for  a  tubercular  teacher  to  get  a  clean  bill  of  health  from 
a  physician,  and  the  periodical  examination  should  be 
made  compulsory.  Teachers  as  a  class  have  more  than 
their  share  of  tubercular,  nervous,  and  other  ailments. 
That  the  teacher  be  in  good  health  is  a  prerequisite  to  the 
proper  health  care  of  her  pupils. 

The  teacher,  also,  must  be  educated  for  this  health  work 
as  well  as  the  doctors  and  nurses  after  they  enter  the 
system.  A  valuable  medical-supervision  library  has  de- 
veloped in  the  past  four  years  and  each  school  system 
should  provide  its  teachers  with,  at  least,  one  simple  well 
illustrated  book  on  the  subject,  say  Hoag's  ''Health  Index" 
or  Cornell's  "Health  and  Medical  Inspection  of  School  Chil- 
dren," F.  A.  Davis  Co.,  Philadelphia,  as  well  as  the  other 
educative  means  discussed.  Dresslar's  "School  Hygiene" 
(Macmillan)  is  very  desirable  for  the  whole  health  field. 
In  the  teachers'  hands  very  largely  must  remain  the  health 
destines  of  the  children,  and  this  responsibility  and  this  op- 
portunity can  never  be  entirely  shifted. 

SUPERINTENDENT'S  ANNUAL  REPORT  ON  MEDICAL 
INSPECTION 

Much  in  the  way  of  progress,  records,  and  education 
of  the  public  depends  upon  the  character  of  this  annua1 
public  report.  The  number  of  pages  of  the  present  report, 
devoted  to  this  subject  varies  greatly  even  by  percentages. 
South  Manchester,  Conn.,  probably  gives  a  larger  share  of 
its  report  to  these  newer  health  matters  than  any  othei 
city.  The  plan  of  coming  around  to  health  matters  every 
few  years  for  intensive  and  comparative  treatment  while 
emphasizing  certain  general  features  every  year  is  to  be 
commended.  Some  of  the  features  of  the  regular  report 
rriay  well  be: 

i.  The  summary  of  the  weekly  reports,  which  have 
been  summarized  for  the  newspapers  and  for  each  monthly 
board  meeting  during  the  year,  both  as  to  ailments  and  the 
general  features  given  on  both  sides  of  the  report. 


MEDICAL  INSPECTION  PLAN  355 

2.  Comparison  with  the  work  of  former  years. 

3.  Interpretation  of  the  data  presented. 

4.  Some  of  the   interesting    cases    handled  during  the 
year,  to  give  the  intimate  personal  side,  with  photographs, 
if  possible. 

5.  Emphasis  on  the  percentage  of  ailments  cured. 

6.  The  principal  needs  and  problems,  and  what  parents 
can  do  to  help. 

7.  Appreciative  words  for  the  various  voluntary  health 
agencies  that  have  helped  during  the  year,  the  newspapers, 
bequests  for  school  clinics,  etc.     How  the  various  divisions 
of  the  hygiene   department   have  co-operated. 

8.  A  general  estimate  of  the  health  conditions  of  the 
school  children. 

III.   MEASURING  THE   EFFICIENCY  OF  MEDICAL  INSPECTION 

SYSTEMS 

The  principal  efficiency  tests  are  the  percentage  of  the 
serious  ailments  existing  in  the  school  population  that  have 
been  found  and  the  percentage  of  the  ailments  found  that 
have  been  cured.  The  decrease  in  ailments  found  from 
year  to  year  due  to  prevention  and  curative  measures  (not 
to  changes  in  the  standards  of  inspectors)  is  a  third  essential 
factor.  In  another  place  (chapters  on  ailments,  and  in  the 
table  of  ailment  frequencies)  the  writer  has  given  an  esti- 
mate of  the  approximate  percentages  of  serious  ailments 
to  be  found  in  an  ordinary  school  population  at  the  present 
time  with  which  comparisons  may  be  made.  Among  a  host 
of  other  tests  of  efficiency  of  this  work  are  the  following: 

1.  Number  of  physicians  and  nurses  in  proportion  to  the 
school  population,  and  the  number  of  nurses  in  relation  to 
the  number  of  physicians. 

2.  The  qualifications   and  the   character   of  the   super- 
vision of  these  officials. 

3.  The  percentage  of  the  school  population  inspected 
and  examined,  and  the  frequency  of  these. 


356    SCHOOL  HEALTH  ADMINISTRATION 

4.  The  quality  of  the  reporting  system,  whether  it  em- 
phasizes essentials,  and  whether  it  promotes  accurate  records 
with  minimum  loss  of  time  from  other  work. 

5.  The  annual  number  of  hours  of  work  for  physicians 
and  nurses,  and  the  regularity  and  punctuality  of  attendance 
upon  such  work. 

6.  The  reasonable  freedom  from  epidemics,  closing  of 
schools,  deaths  of  school  children,  large  amount  of  exclu- 
sion, quarantine,  illness,  absence  and  elimination,  etc. 

7.  The  quality  of  the  methods  of  doctors  and  nurses 
to  be  determined  by  expert  observation. 

8.  The  amount  of  state-aid  money  obtained  because  of 
efficiency  demonstrated  to  the  State  Supervisor  of  Hygiene. 

REFERENCES 

Some  of  the  literature  which  will  be  of  value  in  adapting 
this  system  to  particular  cities  or  rural  regions,  and  the 
first  four  groups  now  procurable  largely  for  the  writing  are : 

1.  1911-12  report  of  the  Chief  Medical  Officer,  Dunfermline,  Scot- 
land. 

2.  Monograph   bulletins  on  the   medical   inspection  of  school   chil- 
dren in: 

Board  of  Education  Cities,  such  as  Celveland,  St.  Louis,  South 
Manchester,  Conn.  (1912  report),  Milwaukee,  Newark,  Trenton, 
Yonkers,  Toronto,  Canada  (Lina  H.  Rogers),  Berkeley,  San  Jose  and 
Oakland,  California,  College  of  The  City  of  New  York  (Dr.  Thos. 
Storey,  on  high  school  medical  supervision),  State  Board  of  Education 
of  Massachusetts,  Boston,  etc.,  Meriden,  Conn. 

Board  of  Health  Cities,  such  as  the  New  York,  Chicago,  Providence, 
State  Board  of  Health,  Connecticut;  State  Boards  of  Health  of  Vir- 
ginia and  Kansas  (Health  Almanacs),  etc. 

3.  Annual    Report   of   the   Chief   Medical    Officer   of   the   English 
Board  of  Education,  London,  England.      This  gives  a  list  of  good  city 
and  rural  reports. 

4.  Annual   Reports  of  the  Chief  Medical  Officer   for  the   London 
County  Council,    London,  England. 

5.  Books:      Mortroe's    "Cyclopedia    of    Education,"    five    volumes. 
Health  articles. 

Gulick  and  Ayres,  "Medical  Inspection  of  School  Children." 
Cornell,  "Health  and  the  Medical  Inspection  of  School  Children." 
Hoag,  "The  Health  Index  of  Children." 
Denison's  "Helping  School  Children." 

Wood:  "Health  and  Education,"  and  "The  Nurse  in  Education," 
U.  of  Chicago  Press. 


MEDICAL  INSPECTION  PLAN  357 

Lina  H.  Rogers,  "The  School  Nurse,"  soon  to  be  published. 

Burks  "Health  and  the  School,"  Appleton's. 

Hutt,   "Hygiene   for   Health   Visitors,    School    Nurses,    and    Social 
Workers,"  P.  S.  King  &  Son,  London,  Eng. 

Moll,  "The  Sexual  Life  of  the  Child." 

Hutchinson's  "Handbook  of  Health." 

Ditman's  "Home  Hygiene  and  the  Prevention  of  Disease." 

Gillette,  "Constructive  Rural  Sociology." 

Kelynack,   "Medical   Examination  of  Schools   and   Scholars,"   King 
&  Son,  London,  Eng. 

Holmes,  "The  Conservation  of  the  Child." 

Dresslar,  "School  Hygiene." 

Terman,  "The  Teacher's  Health." 

"Exercise  in  Education  and  Medicine,"  McKenzie,  Saunders  Co., 
Philadelphia. 

Shaw,  "School  Hygiene." 

Scripture,  "Stuttering  and  Lisping." 

"The  Child  in  the  City,"  by  the  Chicago  School  of  Philanthropy. 

Putnam,  "School  Janitors,  Mothers  and  Health,"  American  Acad- 
emy of  Medicine  Press,  Easton,  Pa. 

Marshall,   "Mouth   Hygiene." 

Hoag  and  Terman,  "Health  Work  in  the  Schools,"  in  preparation. 

Hutchinson,  "Common  Diseases." 

Gulick,  "Hygiene  Series,", Ginn  &  Co. 

Ritchie,  "Hygiene  Series,"  World  Book  Co. 

Colton,  "The  People's  Health." 

Holt,  "Diseases  of  Infancy  and  Childhood." 

McCombs,  "Diseases  of  Children  for  Nurses." 

Hoxie,  "Practice  of  Medicine  for  Nurses." 

"The  Public  Health  Movement,"  The  Annals  for  March,  1911. 

Ditman,  "Education  in  Preventive  Medicine,"  Columbia  University 
Press. 

Wile,  "Sex  Education." 

Woodworth,  "The  Care  of  the  Body." 

Hough  and  Sedgwick,  "The  Human  Mechanism.", 

Rapeer,  "Educational  Hygiene"  and  "School  Health,"  in  preparation. 

Lippert  and  Holmes,  "When  to  Send  for  the  Doctor." 

Sandiford,  "The  Mental  and  Physical  Life  of  Children,"  Longmans. 

Sill,  "The  Child." 

"Annotated  Bibliography  of  Medical  Inspection  and  Health  Super- 
vision of  School  Children  in  the  United  States  for  the  years  1909-1912," 
a  free  bulletin  (No.  524)  by  the  U.  S.  Bureau  of  Education,  Wash- 
ington, D.  C. 

"A  Bibliography  on  Educational  Hygiene,"  by  Thos.  Wood  and 
Mary  Reesor,  M.  A.,  Teachers  College,  Columbia  University,  1911. 

"Annotated  List  of  Text  and  Reference  Books  for  the  Training 
School  for  Nurses,"  prepared  by  the  Department  of  Nursing  and 
Health,  Teachers  College,  Columbia  University. 

See  also  the  biblography  prepared  by  the  author  for  his  section  on 


358    SCHOOL  HEALTH  ADMINISTRATION 

"The  Hygiene  of  the  High  School"  in  Johnston's  "High  School  Edu- 
cation," Vol.  II. 

6.  Bureaus:    The   Division   of    Child    Hygiene,    Sage    Foundation, 
N.  Y.  City. 

Bureau  of  Municipal  Research,  N.  Y.  City. 

United  States  Bureau  of  Education. 

Reports  of  the  National  Education  Association,  Educational  Hygiene 
Articles. 

The  Journal  of  the  American  Medical  Association,  Chicago,  re- 
ports on  medical  supervision. 

Proceedings  of  the  National  and  of  the  International  School  Hygiene 
Congresses. 

7.  Magazines:    Current  educational  and  other  literature  has  many 
articles  on  these  subjects,  all  of  which  can  be  found  in  any  of  the  guides 
to  periodical  literature  found  in  any  public  library. 

*See  also  the  bulletin  of  the  U.  S.  Bureau  of  Education  No.  524, 
pp.  130-131;  and  Dr.  Dresslar's  article  on  "Typical  Health  Teaching 
Agencies  of  the  United  States,"  in  the  report  of  the  U.  S.  Commis- 
sioner of  Education,  Vol.  I. 


INDEX 


Abscess,    182. 

Adenitis,    170. 

Abstract  of  the  book,   7-13 

Adenoids,    141. 

Administration  of  Educational  Hy- 
giene, 11. 

Administration,  general  (tables),  76- 
77. 

Agencies,  Health,  56. 

Ailments  of  School  Children,  138  ; 
summarized,  225  ;  tables,  226,  etc. 

Anemia,    147. 

Annual  Report  of  Supt.,  350. 

Ayres,   Dr.    L.   P.,   32,   38. 

Bachman,    Dr.    Frank,    36. 

Backward    children,    176. 

Biggs,    Dr.,   25. 

Binet    tests,    177. 

"Bladder    trouble,"    202. 

Blepharitis,    196. 

Boards    of    Education     vs.     Boards     of 

Health,    83,    166,    243,    247. 
Boils,   182. 

Books   on   Educational   Hygiene,    135. 
Boy   Scouts,   272,   273. 
Broome,   Supt.   E.   C.,   40. 
Bronchitis,    183. 
Brubacher,   Supt.   A.   R.,   45. 
Budget   exhibits,    241. 
Burnham,  Prof.  Win.   H.,  272. 

Cabot,    Dr.   Arthur   T.    (deceased),   303. 

Case  card  system,  349. 

Catarrh,    189. 

Chapin,    Dr.    C.    V.,    166. 

Checks  on  Work  of  Doctors  and  Nurses, 

95. 

Chest  defects,   179. 
Chicken   Pox,   215. 
Children's    bureau,    57. 
Chorea,   177. 

Cities,  The  twenty-five,  75,  254. 
Classification    of    ailments,    135,    352. 
Cleanliness    needed,    187. 
Clement,   Sect.   P.   P.,   304. 
Clinics,   155,   228,   232,   306. 
Colds,    190. 
Colton's    "Handbook     of     the     People's    ! 

Health,"    288. 
Common    non-infectious    ailments,    182,    j 

184,   185. 

Communicable    ailments,    tables,    205-7. 
Conclusions      on      Medical      Inspection, 

257. 

Conjunctivitis,  204. 
Consultations   with   mothers,   241. 
Consumption,    222. 
Contagious    ailments,    203. 
Cornell,    Dr.    W.    S.,    98. 
Coryza,    190. 

Cost   of   Medical    Supervision,    86. 
Crandall,    Prof.    Ella   P.,    304. 
Cross-eye,   168. 
Cruickshank,    Dr.    L.    D.,    244. 
Cures,   131. 

Davenport,  Dr.  Chas.  B.,  16,  65. 

Deafness,    148. 

Death  :     causes,    22  ;    in    the    25    cities, 

207  ;   lo^ses^,  see  "Economic." 
DebiTity,    175. 

Defective   pupils,   percentage,   129,    352. 
Deformities,   179. 


Demarest,   Supt.  A.   J.,   37. 

Dental   defects,    151. 

Desks,    school,    284. 

Dewey,    Prof.    John,    14. 

Diphtheria,   216. 

Directions   for  making  reports,  346. 

Disinfection,   242. 

Doctors    and    nurses :     number,    78-79  ; 

work,    80-81. 

Doctor's   examinations,   333. 
Dressier,   Prof.   F.   B.,   66. 
Drinking    fountains,    282. 
Dunfermline,    178,    189. 
Dust   absorbing  compounds,   285. 

Ear  ailments,  minor,  194 ;  discharge 
(otitis),  192. 

Economic  losses  from  ill  health,  8-9, 
21-27,  30-33. 

Eczema,  .195. 

Educational  Hygiene  :   divisions  of,  296. 

Efficiency  tables,  253.  General  effi- 
ciency, 351. 

Elimination,    34. 

Eneuresis,   202. 

Enlarged  tonsils,    157. 

Epistaxix,    198. 

Eugenics,   65. 

Examinations :  100,  102,  113  ;  num- 
ber, 120  ;  vision,  123,  327. 

Expenditures    for    Medical    Supervision, 

<      299,    301. 

Exclusions  :  and  retardation,  46  ;  form 
and  method,  319-320. 

Eyes,   minor   ailments,   196. 

Eyesight,    122,    161. 

Farr,    32. 
Favus,    208. 
Feeding,   175-176. 
First-aid,  201. 
Fiscal  fallacy,  219. 
Fisher,   Prof.   Irving,   18-30. 
Flexner,   Dr.  A.,  18. 
Foley,  Sect.  Edna  L.,  304. 
Foster,    Dr.    N.    K.,    303. 
Fountains,    drinking,    282. 
Frequency    of    ailments,    226-227,    248- 
349,    352. 

Giddings,   Prof.   F.   H.,   309. 

Glands   enlarged,   170. 

Glasses,   167. 

Goddard,   Prof.   H.   H.,   177. 

Gorgas,    W.    C.,    54. 

Grippe,    209. 

Gulick,  Dr.  Luther  H.,  26,  272,  288. 

Gymnasiums,   275. 

Hall,  President  G.   S.,   294. 

Health  agencies,   55-60. 

Health   record   cards,   311,   315. 

Hearing  :     148  ;   tests,  332. 

Heredity,  65. 

Hermann,  Dr.  Ernst.  266. 

High    School   Medical    Supervision,    104, 

258-259,   273-277. 
Hoag,   Dr.   E.   B.,    134. 
Holmes,  Dr.  Geo.   J.,  96. 
Home  visits,  325. 
Howerth,  Prof.  Ira  S.,  70. 
Hygiene   of   School   Room,   61. 
Hygiene   of   Teaching  or   "Instruction," 

289,    296. 


INDEX 


Illness   losses,  summary,   47. 

Impetigo,    209. 

Infectious  diseases,   214 ;   table,   207. 

Influenza,   209. 

Inspections,  124,   127. 

Investigations,   health,   243. 

Itch    (scabies),  212. 

Johnston,  Prof.  Chas.  H.,  259,  269. 
Keyes,  Dr.  Chas.  H.,  33-34. 

Lamson.   Dr.   W.    J.,   152. 

Laryngitis,  197. 

Laws   on   Medical    Inspection,   62. 

Lectures,  236. 

Lice,   209. 

Lisping,  180. 

Locke  and   Floyd,   23. 

Lungs  weak,   10. 

Lubin  Vitagraph  Co.,  57. 

Mackey,    Supt.   E.,   42. 

McKenzie,  Prof.  R.  T.,  276. 

Malnutrition,    175. 

Measles,   220. 

Medical  attendance  expense,   24. 

Medical    Supervision,   divisions   of,    305. 

Medical   supplies,   93,   232. 

Mentality   defective,   176. 

Method  of  inspection,  308,  317. 

Mortality  statistics,  19. 

Mothers'    consultations,    241. 

Mouth  hygiene,   151. 

Mumps,    221. 

National  vitality,  21. 
Nearing,    Prof.    Scott,    23. 
Negative   cases,   144. 
Nervous  ailments,  177. 
Neuralgia,  197. 
Neurologists,    236. 
Newman,   Sir  Geo.,   145. 
Nomenclature,   tentative  standard,    352 
Nose-bleed,  epistaxis,  198. 
Notice  to  parents,  335. 
Nurse-alone  plan,   302. 
Nurses :    where   to   get   them,    304 ;    in- 
spection by,  127. 
Nutritional   index,    176. 
Nutting,    Prof.    M.    A.,    304. 

Oculists,   236. 

Oils,  floor,  285. 

Open-air  schools,  239. 

Orthopedic   defects,   179. 

Otitis  media  ear  discharge,   192. 

Otorrhea,  192. 

Palate  defects,  179. 
Parental  education,  339. 
Part-time  physicians,   303. 
Pasteur,   Louis,   18. 
Pediculosis,    209. 
Pertussis,   whooping  cough,   224. 
Pharyngitis,  198. 

Physical   defects,   134,   141,   352  ;    sum- 
mary table,  184. 

Physical  education,  296  ;  table,  263. 
Pink  eye,   conjunctivitis,   204. 
Playgrounds,    64,    276. 
Posture,    179. 
Prescriptions,   235. 
Prevention,    239. 

Preventable    deaths,    1&.-20,    29-30 
Principals'   reports,   349. 
Private  organizations,   237. 
Promotion,   34. 
Public  health^  17. 

Quarantine   and   retardation,   46. 
Quinsy,  213. 


Ranking   of   the    25    cities,    254. 
Reports    of    doctors     and     nurses      341 

and   343-4. 
Retardation,   34. 
Reik,  Dr.   H.   O.,  158,  168. 
Rheumatism,    198. 
Rhinitis,   189. 
Ringworm,   211. 
Ritchie    Hygiene    Series,    288. 

Salaries  of   physicians   and   nurses,   87, 

90. 

Salaries,    75. 
Sanitary  inspection  of  home  and  school 

280,  296,  326. 
Scabies,  itch,  212. 
Scarlet  fever,   221. 
Schedules,  99. 
School    children,    death    losses,    28,    29, 

School  Board  Journal,   275,  283. 

Scientific  management,   298. 

September  classroom   inspections    307 

Sex  ailments,   199. 

Shoulders,  round,  179. 

Signs    for    medical    inspection    reports, 

310. 

Skeletal    defects,    179. 
Skin  ailments,  minor,  200. 
Sore  throat,   acute,    182. 
Speech  defects,  180. 
Spinal  curvature,  179. 
Squint,    168. 
Standardization    of    medical    inspection, 

305-306. 

Statistical   fallacies,   31 
Stomatitis,  200. 
Storey,  Dr.  Thos.,  105,  258. 
Strabismus    (cross-eye  or  squint),   168. 
Stuttering    and    stammering,    180 
Strayer,   Prof.   G.    D.,   6,   29,   32. 
Styes,    196. 
Supplies    for    medical    supervision,    92 

232. 

Summaries  7,  47,   64,  107,  257,   290. 
Supervisor    of    hygiene    297. 
Suzzallo,   Prof.   Henry,   6. 

Teacher's  medical   inspection,   349. 

Teaching   hygiene,    287,    296 

Teeth   defects,   151. 

Tendencies   in   medical   supervision,   84. 

Terman,   Prof.   L.   M.,   72. 

Thorndike,  Prof.  B.  L.,  6. 

Treatments,   231. 

Throat,  sore,   182. 

Time  employed   in  medical   supervision, 

94. 

Tonsolitis,   213. 
Tonsils,  enlarged,  157. 
Towels,  paper  and  cloth,   286. 
Trachoma,  granulated  eye-lids,  222. 
Tubercular  glands,  170. 
Tuberculosis,   of   lungs,    222 ;    of   bones, 

etc.,   224. 

Urinary    ailments,    202. 

Vaccination,    339. 
Vacuum  cleaning,  283. 
Verplanck,   Supt.   F.   A.,   43. 
Vision    defects,    161,    163,    122. 
Vision   tests,    330. 

Wallace,  A.   R.,   65. 

Wallin,   Prof.   J.   E.   W.,  48. 

Whooping  cough,  224. 

Wilcox,  19. 

Work     certificate     examinations,      102 

242. 
Wounds,  sores,  sprains,  etc.,  201. 


VITA 

Louis  Win  Rapeer,  born  at  Cincinnati,  Ohio,  Decem- 
ber 23,  1879. 

Graduated  and  received  the  diploma  in  education  from 
the  Indiana  State  Normal  School,  Terre  Haute,  Indiana, 
in  1902;  received  the  degree  of  Bachelor  of  Science  from 
the  University  of  Chicago  in  1904;  and  the  degree  of 
Master  of  Arts  from  the  University  of  Minnesota  in  1907. 

Was  a  teacher  in  the  elementary  schools  of  Indiana  for 
five  years,  and  later  became  principal  of  a  high  school  for 
one  year  and  a  superintendent  of  schools  for  one  year. 
For  four  years  was  a  principal  of  elementary  schools  in 
Minneapolis.  During  the  summer  of  1908  was  an  instructor 
in  the  municipal  playgrounds  of  Minneapolis,  and  the  next 
summer  was  instructor  in  educational  psychology  and 
educational  administration  in  the  University  of  Minnesota. 
In  1909  became  Assistant  Professor  of  Education  in  the 
University  of  Washington,  Seattle.  In  1910  was  a  graduate 
scholar  in  Teachers  College,  Columbia  University  and  an 
Assistant  Tutor  in  Economics  at  the  College  of  the  City 
of  New  York.  Since  1911  has  been  an  assistant  teacher 
in  educational  psychology,  logic,  and  school  management  at 
the  New  York  Training  School  for  Teachers. 


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